Retrospective Clinical Comparison of Celsior Solution to Modified Blood Wallwork Solution in Lung Transplantation for Cystic Fibrosis

Objective

To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation.

Methods

From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution.

Results

Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant).

Conclusion

Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.

Phase II trial of extrapleural pneumonectomy followed by adjuvant radiotherapy in malignant pleural mesothelioma

7579

Background: This phase II clinical study was conducted to evaluate the effectiveness of the association of extrapleural pneumonectomy followed by radiation therapy in patients with potentially resectable malignant pleural mesothelioma (MPM). Methods: Eligible patients had histologically proven epithelial or mixed MPM with clinical stage T1–3, N0–2, M0 disease considered to be completely resectable and a WHO performance status of 0 or 1. Surgery had to consist of a complete extrapleural pneumonectomy including resection of pericardium and diaphragm. Postoperative radiotherapy (40 Gy) was delivered through anterior and posterior fields, with a 10 to 20 Gy boost dose if necessary. Results: Thirty seven patients were included in this study. Extrapleural pneumonectomy was completed in 35 patients. Overall hospital mortality was 5,7 %. Major post operative complications were: 3 acute lung injury, 1 bronchopleural fistula, 1 stroke, 1 chylothorax and one diaphragmatic patch dehiscence. IMIG post-operative staging was: stage II = 5 patients; stage III = 25 patients; stage IV = 5 patients. Adjuvant radiation was administered to 29 patients. Survival for the 35 patients with complete resection was 47 ± 8 % at 2 years. Median overall survival time was 22 months. Survival without recurrence was 37 ± 8 % at 2 years. Median time to progression was 15 months. Locoregional recurrence is the most common form of relapse. Conclusions: In the era of surgical neoadjuvant therapy in MPM treatment, extrapleural pneumonectomy followed by radiation therapy in patients with resectable epithelial or mixed MPM can achieve acceptable results.

No significant financial relationships to disclose.

[Anthracycline-induced heart failure aggravated by pregnancy. Survival after cardiac assistance with artificial heart device and heart transplantation]

We report a case of a young woman suffering from a steady anthracycline-induced myocardiopathy with a decreased left ventricular function on echocardiography. A pregnancy was initiated, without worsening of the cardiopathy until 34 weeks. Nine days after delivery, an acute heart failure was observed leading to heart transplantation after cardiac assistance with heart cardiac device. As pregnancy is an extended stress test for a chronic failing heart, a multidisciplinary decision of pregnancy initiation and follow up should be preferred in pre and postpartum period, when such a cardiopathy exists.

[The long term (15 years) evolution after valvular replacement with mechanical prosthesis or bioprosthesis between the age of 60 and 70 years]

OBJECTIVE

the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life.

METHODS

a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis.

RESULTS

the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p<0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3).

CONCLUSION

the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

Resection of bronchopulmonary cancers invading the left atrium--benefit of cardiopulmonary bypass

AIMS

Cardiopulmonary bypass (CPB) for extended lung resections involving great vessels and other mediastinal organs remains controversial, especially due to CPB-related haemorrhagic and immunological issues. Here, we will retrospectively analyse the results obtained with such procedure.

MATERIAL AND METHODS

Between January 1994 and February 2001, four patients underwent surgery under CPB for lung carcinoma in our department. Three patients were male and one female; mean age was 58.8 +/- 6.3 years. The patients suffered from malignant pulmonary lesions involving the left atrium (T4 or stage IIIb) - two epidermoid carcinoma, one adenocarcinoma and one large-cell carcinoma. Procedures were performed under complete CPB with aortic cross-clamping in all but one patient who underwent hypothermic ventricular fibrillation. Mean CPB duration was 86.7 +/- 26.5 min.

RESULTS

There were no hospital mortalities (D30). Mean duration for assisted ventilated support was 9.5 +/- 2.5 hours, 2.5 +/- 1 days for ICU stay and 14.3 +/- 1 days for hospital stay. Operation-related complications were rare. Two patients presented with transient postoperative atrial fibrillation. Only one patient had to undergo reoperation for compressive haemopericardium drainage at D23. The mean quantity of transfused packed red blood cell packs was 2.7 +/- 1.7. Two patients survived over three years after surgery and one patient is still alive at 72 months without any recurrent symptom.

CONCLUSION

In some cases of T4 lung cancer considered inoperable, CPB permits extended lung resections offering significant hope for survival at an acceptable operative risk.

Retrospective clinical comparison of Celsior solution to modified blood Wallwork solution in lung transplantation for cystic fibrosis

OBJECTIVE

To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation.

METHODS

From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution.

RESULTS

Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant).

CONCLUSION

Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.

[Mid-term results of stentless bioprosthesis for aortic valve replacement. Experience in a series of 97 patients]

Stentless bioprostheses have been described as valve substitutes of interest for aortic valvular replacement. We studied 97 consecutive patients with a mean age of 72.2 years (40-84) who underwent aortic valvular replacement with 80 Toronto SPV and 17 Freestyle prostheses. Operative mortality was 6.2. With a mean follow-up of 19 +/- 10 months (1-46), 87.2% of the surviving 86 patients underwent an echocardiography performed by the same operator. Mean gradient was 10.9 +/- 3.6 mmHg (4.2-22.6) and effective orifice area was 1.8 +/- 0.5 cm2 (0.8-3.0) for the 75 controlled stentless valves. The best haemodynamic data were obtained with the 25 mm diameter prostheses. One asymptomatic partial dehiscence was observed during monitoring. None of the 15 detected aortic leaks was significant. We observed a significant reduction of the ventricular mass in 41 patients who had undergone pre- and postoperative evaluation (p < 0.0014). Overall survival was 86.8 +/- 4.4% at 2 years. Stentless bioprostheses offered satisfactory haemodynamic results in our series. They however require an implantation technique learning curve as well as a thorough knowledge of the aortic root anatomy and physiology.

Isolated mitral valve replacement with St. Jude medical prosthesis: long-term results: a follow-up of 19 years

BACKGROUND

In this retrospective study, approximately 440 patients received mitral valve replacements with the St Jude Medical prosthesis. The last patient was operated on 10 years before the beginning of the follow-up. The extended follow-up was 19 years.

METHODS AND RESULTS

Four hundred forty patients (sex ratio, 1.32 [men to women]; age, 60+/-11.4 years; age range, 7 to 75 years) were operated on from 1979 to 1987. All patients underwent isolated mitral valve replacement. Tricuspid plasty was the only associated procedure. The follow-up at 19 years was 98% complete. The overall actuarial survival rate was 63+/-3.3% at 19 years, and the actuarial survival rate (only valve related) was 83+/-2.7%. The operative mortality rate (0 to 30 days) was 4.09%. We found that 89.4% of the patients alive at 19 years were in NYHA class I/II. Multivariate analysis showed that age and sex were significantly correlated with valve-related mortality and that age, sex, NYHA class, and atrial fibrillation were significantly correlated with overall mortality. The linearized rates (percent patient-years) of thromboembolism, thrombosis, and hemorrhage were 0.69, 0.2, and 1, respectively. At 19 years, freedom from endocarditis and reoperation was 98.6+/-1% and 90+/-3%, respectively.

CONCLUSIONS

In this study, the very-long-term results confirm the excellent durability of the St Jude Medical prosthesis in the mitral position and show the difficulty of adjusting the anticoagulation protocol, even after long-term treatment.

[Surgical treatment of pulmonary metastases of colorectal cancers. 8-year survival and main prognostic factors]

OBJECTIVE

In order to achieve a better definition of the indications for surgical excision of pulmonary metastases in colorectal cancer (CCR), a retrospective study of the eight year survival of patients who had been operated on was carried out with reference to the principal prognostic factors.

METHODS AND RESULTS

Between May 1986 and December 1997, 38 patients had an excision for pulmonary metastases for CCR. The mean delay between diagnosis of the metastases and surgical treatment of the CCR was 39 +/- 24 months (0-98). Thirty two patients (84%) had a single pulmonary metastasis. The mean diameter of the metastasis was 38 +/- 22 mm. Twenty metastases had a diameter < 30 mm. Five patients had a locoregional recurrence of their CCR before pulmonary surgery. Fourteen patients had an abnormally elevated level of carcinoembrionic antigen (ACE-CEA) before the pulmonary excision. Five pneumonectomies, 23 lobectomies, 1 bilobectomy and 11 atypical resections were carried out. A lymph node clearance was performed in 25 cases. Six patients (16%) had an associated excision of an hepatic metastasis. The in-hospital mortality was 2.6%. Chemotherapy was associated with a pulmonary excision in 17 patients (46%). The mean survival was 2.7 years (0.13-8.7 years). The survival at one year was 89 +/- 5.2% and at five years 35.2 +/- 10.1% and at eight years 18.8% +/- 10.3%. Age, sex, histological stage of the primary tumor, the size and the delay in appearance in the pulmonary metastases, the number of metastases, the preoperative CEA, the operative technique and the perioperative chemotherapy did not influence the levels of survival at five years. At the same time associated excision of an hepatic metastasis did not worsen the prognosis at five years.

CONCLUSION

Complete excision of pulmonary metastases in a colorectal cancer allows for significantly longer survival. This study associated with a literature review may help in advancing towards better selection of surgical candidates.

[Mucoviscidosis: lung transplantation is always in order]

THE ONLY SOLUTION: Despite significant progress in the management of patients with multiple sclerosis, lung transplantation remains the only chance for survival in those with severe respiratory failure.

WAITING LIST INCLUSION CRITERIA

Lung function tests, the patientís general states and psychological and familial factors all contribute to determining inscription on lung transplantation waiting lists.

TECHNICAL ASPECTS

Heart-lung, monoblock two-lung and sequential two-lung transplantations are detailed according to the respective advantages and disadvantages.

RESULTS

Hospital mortality is about 5% and 5-year survival about 50%. However, only 10% of the patients on waiting lists due to the lack of organs survive for 2 years.

PERSPECTIVES

The number of grafts must be increased by developing lobular grafts from live donors using the bipartition technique. Nevertheless, xenografts remain the most promising perspective for increasing the number of patients who can benefit from this therapy.

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer

OBJECTIVE

Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula.

METHODS

Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases.

RESULTS

The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046).

CONCLUSIONS

Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.

[Pulmonary endodermal tumor resembling fetal lung. Low grade adenocarcinoma of the fetal lung type]

Pulmonary endodermal tumor resembling fetal lung is a rare pulmonary neoplasm, classified either within the pulmonary blastomas spectrum or as a subtype of adenocarcinoma. We report a case revealed by a fever in a 24-year-old woman. The tumor measured 9 cm and extended into the lower right bronchus. The diagnosis was done on a biopsy performed during fiberoptic endoscopy. The patient was treated by lobectomy. She is well without disease 6 years after surgery. This type of predominantly epithelial tumor with neuroendocrine differentiation and a scanty non malignant stromal component should be identified in young women because of its favorable outcome after surgical resection. It must not be confused with ordinary adenocarcinoma nor metastatic adenocarcinoma, especially endometrioid type.

Mitral valve replacement with the St. Jude Medical prosthesis: a 15-year follow-up

BACKGROUND

A retrospective study was conducted to analyze the results of St. Jude Medical mitral valve replacement.

METHODS

From January 1979 to December 1989, 870 patients (54% women, 46% men; mean age, 55.8 +/- 6.2 years) underwent mitral valve replacement with the St. Jude Medical prosthesis. Of these operations 616 were isolated mitral valve replacements and 254 were double valve replacements. Coronary artery bypass grafting was performed concomitantly in 55 patients (6.3%).

RESULTS

Overall, early mortality was 5.05%, with 4.2% for the isolated mitral valve procedure and 7.08% for the double valve replacement. Follow-up at 15 years was complete in 859 patients (98.74%). Mean follow-up time was 93.5 months, for a total of 6,436 years. Actuarial survival at 15 years was 59.5% +/- 5%, 60.5% +/- 6%, and 56.9% +/- 9%, for the entire group, the isolated mitral valve and double valve procedures, respectively. Multivariate analysis identified age, sex, hospital stay, and preoperative mitral regurgitation as independent prognosis factors for overall mortality. Of 606 patients alive at the latest follow-up, the New York Heart Association class improved significantly (from 67% class III/IV before the operation to 88% class I/II after the operation). All patients received warfarin to maintain an international normalized ratio between 3.5 and 4. The linearized rates (% per patient-year) of thrombosis, thromboembolism, and major hemorrhage were, respectively, 0.21, 0.75, and 0.94 for the entire group; 0.18, 0.67, and 0.88 for the isolated mitral valve operation; and 0.15, 0.92, and 1.08 for the double valve replacement. For the entire group the freedom from thrombosis and thromboembolism at 15 years was 98.1% +/- 1% and 88% +/- 4%, respectively. No case of structural dysfunction occurred. The freedom from paravalvular leak and endocarditis at 15 years was 95.3% +/- 2% and 97.3% +/- 2.4%, respectively. The probability of remaining free from reoperation at 15 years was therefore 95.6% +/- 2.5%.

CONCLUSIONS

These results confirm that the St. Jude Medical valve is a reliable prosthesis with very low thrombosis and thromboembolism rates, allowing the use of a low dose of anticoagulation with an international normalized ratio of about 3.

Aggressive surgical management in localized pulmonary mycotic and nonmycotic infections for neutropenic patients with acute leukemia: report of eighteen cases

OBJECTIVE

To prevent hemoptysis and relapse during subsequent chemotherapy-induced neutropenia in patients with localized forms of invasive pulmonary aspergillosis, we adopted an aggressive surgical approach.

METHODS

From 1988 to 1996, 18 patients with hematologic diseases were referred with the diagnosis of localized invasive pulmonary aspergillosis. The diagnosis was based on clinical features, failure to respond to antibiotic therapy, an air crescent sign suggestive of aspergillosis on the computed tomographic scan (39%), and retrieval of fungi by bronchoalveolar lavage (44%).

RESULTS

The following procedures were done: one pneumonectomy, four bilobectomies, seven lobectomies, six wedge resections, and one lobectomy with wedge resection (one patient had two procedures). No perioperative deaths or complications occurred. The histologic examination confirmed the diagnosis of invasive pulmonary aspergillosis in 12 patients. The six other diagnoses were as follows: one case of classic aspergilloma, one case of pneumonia, and four cases of pulmonary abscess. According to univariate analysis, thoracic pain was less common in the group with noninvasive pulmonary aspergillosis (1/6) than in the group with invasive pulmonary aspergillosis (8/12) (p < 0.05). Sixteen patients required subsequent hematologic treatments. Sixty-six percent of the patients are alive with a mean follow-up of 29.1 +/- 27.8 months (range 2 to 103 months), with no statistically significant difference between the invasive and the noninvasive pulmonary aspergillosis groups. Five patients died of a recurrence of their malignant disease at a mean of 17.2 +/- 12.5 months (range 2 to 30 months), and one had a cerebral recurrence of Aspergillus infection during a bone marrow transplantation 3 months later.

CONCLUSION

Aggressive surgical management radically improves the prognosis of invasive pulmonary aspergillosis, even if the surgical indications include some nonmycotic infections because of the difficulty in establishing the clinical diagnosis.

[Thymic and bronchial neuroendocrine tumors in multiple endocrine neoplasia type 1. GENEM1]

OBJECTIVES

Multiple endocrine neoplasia type 1 (MEN 1) mainly affects parathyroid glands, pancreatic islets and pituitary gland. The aim of this study in 95 MEN 1 patients was to examine less frequent localizations thymic and bronchic neuroendocrine tumors (NET).

PATIENTS AND METHODS

Two cases of bronchic NET were observed, both in women, and 4 cases of thymic NET, all in men, giving a prevalence of 7.3%. These NET were often asymptomatic. A metastatic diffusion was observed in 3 cases. Elevated plasma levels of glycoprotein hormone alpha subunit (SU) and FSH were observed in 3 and 1 cases respectively. Immunohistochemistry indicated the tumor cells to be frequently positively stained for HCG alpha and FSH.

DISCUSSION

We conclude that all patients with MEN 1 should undergo screening for thoracic NET, especially in high risk familial subgroups and in case of elevated plasma alpha SU or FSH.

[Combination of true and false left ventricular aneurysm. Cine-MRI diagnosis]

The authors report a case of a 68-year-old man with a history of postero-lateral myocardial infarction complicated by a true and a pseudo-aneurysm of the left ventricle, a chance finding during investigation of a systemic embolism. This is a rare association which is clinically difficult to diagnose. The authors describe the different complementary investigations available to make the diagnosis and underline the value of cine-MRI which was particularly useful in this case. Surgery may be indicated in cases of true aneurysm in cases with left ventricular failure but is mandatory in all cases of pseudo-aneurysm irrespective of the clinical presentation.

[Heart-lung transplantation and cystic fibrosis. Indications and results]

BACKGROUND

Heart lung transplantation for++ cystic fibrosis is now performed in patients with severe lung disease but the experience is still scarce with the exception of some specialized centers.

PATIENTS AND METHODS

Twenty-one patients underwent heart-lung transplantation between September 1989 and November 1994 in our institution, with a high standard of reliability in tracheal anastomosis and with a low incidence of hospital mortality (5%).

RESULTS

The actuarial patient survival is 90.2% (95% confidence interval, 70 to 97%) at 1 year and 75.7% (95% confidence interval, 51 to 90%) at 3 and 4 years. The mean forced expiratory volume in 1 second (FEV1) increases from 20.1% predicted preoperatively to 76.1%.

CONCLUSION

Despite the presence of airway pathogens, these results confirm that heart-lung transplantation for cystic fibrosis leads to a pronounced improvement in lung function and good rehabilitation after surgery. The two main obstacles are the shortage of donor organs and the possibility of late deterioration in lung function with a progressive airflow obstruction.

Surgical resection of pulmonary metastases from colorectal carcinoma. Five-year survival and main prognostic factors

Between 1986 and 1994, 19 patients underwent pulmonary resection for metastatic colorectal carcinoma. The mean interval between colon resection and appearance of pulmonary metastasis was 41 +/- 21 months. All the patients had no more than two metastases. Wedge resection alone or associated with lobectomy was performed in four patients, lobectomy in ten, and pneumonectomy in five. One patient died within the month after surgery. Mean follow-up was 35 +/- 26 months. The 5-year survival rate was 38.7%. Repeat thoracotomy for recurrent metastases was performed in one patient. The disease-free interval, the size of metastases, the type of pulmonary resection, and the location and the stage of primary cancer had no apparent influence on survival, but the survival rate at 4 years was 25% for patients with high carcinoembryonic antigen (CEA) level versus 80% for those with low CEA level. We conclude that, at least when the number of metastases is less than two, resection of colorectal lung metastasis is safe and effective.

Complete myocardial revascularization through a right thoracotomy

We report the case of a 57-year-old woman who benefited from a complete revascularization of the heart, including a circumflex marginal coronary bypass grafting, through a right thoracotomy. This approach avoids sternal wound complications that can occur after high-dose mediastinal radiotherapy and omental flap reconstruction on the sternum.

Localized invasive pulmonary aspergillosis in patients with neutropenia. Effectiveness of surgical resection

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with neutropenia. Two severe complications with poor outcome can be observed after apparently successful IPA medical treatment: severe hemoptysis and IPA relapse during subsequent cytotoxic treatments. Early surgical therapy has not been considered routinely in the management of localized IPA.

METHODS

Six consecutive patients (four women, two men; median age, 52 years) with localized cavitating IPA diagnosed during chemotherapy-induced aplasia were treated with early surgical resection after hematologic recovery.

RESULTS

All patients received a lobectomy. Surgery was uneventful. This procedures allows patients to proceed with further intensive chemotherapy and/or bone marrow transplantation without IPA reactivation.

CONCLUSIONS

For selected patients, surgical resection of localized IPA with unique cavitating lesion, which prevents hemoptysis and IPA recurrence and allows for subsequent cytotoxic treatment, may be recommended.

Sacral pseudomeningocele and Marfan's disease. One case

The authors report a case of sacral pseudomeningocele discovered by chance in a 29-year old male patient presenting with Marfan's disease. In this disease, such abnormalities are common and due to excessive fragility. of the dura mater. CT and MRI provide an accurate morphological analysis and a complete evaluation of lumbosacral osteomeningeal abnormalities.

Retrograde dissections of the aortic arch after exclusion-bypass of the descending thoracic aorta: a report of three cases

We report three cases of fatal retrograde dissection of the aortic arch after exclusion-bypass with metal clamps according to Carpentier's thromboexclusion method. All three patients were male, aged 59, 66, and 73 years. Initial operative indications were chronic dissections in two cases and atheromatous aneurysm of the descending thoracic aorta in the other. Two of these patients were operated on in an emergency setting for a ruptured aneurysm. In all three cases, an extraanatomic bypass between the ascending aorta and abdominal aorta was performed as the first step: The proximal clamp was then placed distal to the origin of the left subclavian artery. Death occurred two hours, 12 hours, and eight days after operation, respectively. Autopsy revealed retrograde dissection initiating in the aortic arch and reaching the aortic ring as the cause of death. Pathological examination of aortic specimens confirmed that the dissections began just proximal to the site of clamping. To explain this complication, two etiologic factors, occurring either alone or together, have been postulated: postoperative hypertension and trauma to the aortic wall from the clamp.

[Cardiac transplantation at the University Hospital Center of Nantes. 2 years' experience]

Between March, 1985 and April, 1987, 25 orthotopic heart transplantations were performed in 20 men and 5 women aged from 17 to 58 years (mean 42 years) on account of cardiomyopathy (n = 15), ischaemic heart disease (n = 6) or miscellaneous lesions (n = 4). The immunosuppressive treatment consisted of antilymphocyte serum and corticosteroids during 10 days; cyclosporine was introduced on the 7th day and continued thereafter in association with low-dose corticosteroid therapy. Endomyocardial biopsies were performed. Acute rejection, responsible for 2 deaths (one on the 10th day, the other in the 10th week), usually occurred within the first 3 months. Infections were frequent and often serious, resulting in one death in the 7th week. One out of patients had to be treated for arterial hypertension, and 3 patients presented with renal impairment (blood creatinine over 200 mumoles/l). The actuarial survival rate at 2 years is 84 p. 100. More than one-half of the patients have resumed social and occupational activities.

Heart-lung transplantation: better use of resources

PURPOSE

Our goal was to review the experience at Papworth Hospital, Cambridgeshire, England, with combined heart-lung transplantation.

PATIENTS AND METHODS

Since April 1984, 31 patients have undergone heart-lung transplantation. Donors and recipients are carefully matched with regards to serology, morphology, and cytomegalovirus compatibility. A pulmonary preservation fluid has been developed that allows distant organ procurement with a single pulmonary artery flush technique.

RESULTS

Acute cardiac rejection has not occurred in these patients. Twenty-three patients are alive between two months and over three years following transplantation. The actuarial survival rate at one year is 78 percent, and 70 percent at two years. Three patients died as a result of cytomegalovirus pneumonitis; in two patients, obliterative bronchiolitis developed, and both died, one after an opportunistic infection developed. Three patients died from other causes. The use of transbronchial biopsy of the lung has provided accurate, early, and safe diagnosis of pulmonary rejection.

CONCLUSION

Developments in organ preservation and patient management, as well as careful selection of recipients and donors, have led to the effective use of resources and thereby to these good results. In particular, the incidence of obliterative bronchiolitis has been low, which is attributed to the early treatment of pulmonary rejection following diagnosis by transbronchial biopsy.

[Heart-lung transplantation. Experience of Papworth Hospital. Apropos of 24 surgical cases]

Between April 5, 1984 and May 9, 1987, 24 patients underwent heart-lung transplantation for a variety of vascular and pulmonary diseases. Graft procurement being usually distant, the cardiopulmonary protection used was based on a simple hypothermic flush technique performed in donors prepared with prostacyclin. There was no primary graft deficiency and no intra-operative death. 17 patients are alive after a follow-up period of 1 to 41 months. The actuarial survival rate at 1 year was 77 p. 100. Late mortality was mainly due to cytomegalovirus infections. Immunosuppression relied on cyclosporine A and azathioprine with peri-operative use of antilymphocyte serum and corticosteroids. Early graft rejection episodes were treated with bolus intravenous methylprednisone. These episodes were detected from combined clinical, radiological, spirometric and histological data. Transbronchial lung biopsy was the reference examination for an objective diagnosis of lung rejection. In this series there was only one case of obliterative bronchiolitis (4 p. 100). This must be credited to the strategy used to detect rejection which seems to be the main factor of occurrence of this dangerous complication.

[Rupture of the left ventricle into the free pericardium in the early stage of a myocardial infarction. Diagnosis using echocardiography and surgical treatment]

A case of subacute left ventricular rupture on the 4th day of an inaugural antero-septal infarction in a 63-year old woman is reported. The diagnosis, suggested by cardiovascular collapse with acute tamponade, was confirmed by echocardiography. Haemodynamic stability was maintained by needle aspiration followed by pericardial drainage, and right heart catheterization long enough for the patient to be transported to a Cardiovascular Surgery unit where surgical repair was successfully performed 9 hours after the rupture. The elements for a positive diagnosis, the value of echocardiography, the various surgical procedures and the favourable long-term prognosis in patients operated upon are discussed.

Cardiac metastases. Case report on an isolated cardiac metastasis of a myxoid liposarcoma

This report describes an isolated case of cardiac metastasis of a myxoid liposarcoma that was successfully resected by surgery after clinical and ultrasound diagnosis. Although cardiac metastases are rarely diagnosed during patients' lifetimes, a search should be made for such lesions whenever cardiac disorders appear suddenly in cancer patients. Echocardiography appears to be one of the best investigative techniques for such purposes. Despite generally poor therapeutic results, surgical resection occasionally permits long periods of survival.

[Coronary intramural ruptures caused by transluminal angioplasty. Incidence, significance and development controlled by coronary angiography]

The authors report their experience of coronary intimal rupture (CIR) observed at control angiography performed at the end of transluminal angioplasty in a series of 150 cases. This lesion was observed in 34 p. 100 of cases. Two subgroups were established according to the presence (Group I: 51 cases) or absence of CIR (Group II: 99 cases) in order to try and identify any predisposing factor. The following features were compared in each group: age, sex, number of risk factors, duration of the disease, its severity, the site and morphology of the lesions (calcification, length, excentric or concentric) on the artery dilated and the technique used (number of inflations, maximal pressure, guidable catheter). The only significant feature associated with CIR was the morphology of the stenosis. Intimal rupture was statistically more frequent when the stenosis was long, calcific and excentric (p less than 0.05). The excentric character was highly predictive of CIR +/- 0.02) and even of complicated CIR (p less than 0.01). The CIR was complicated in 10 cases (19.6 p. 100) with a higher incidence than in the rest of the population (p less than 0.05). These complications were immediate presenting as attacks of angina leading on to 4 myocardial infarctions (7.8 p. 100) but no deaths. The treatment consisted in an attempt to redilate the artery with effective angioplasty in 3 out of 4 cases. Medical therapy alone was sufficient in 2 cases and 4 patients underwent coronary bypass. There were no complications in cases of initially asymptomatic intimal rupture. The 6 months outcome was controlled by coronary angiography in 131 angioplasties.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arterial diseases of the lower limbs in subjects less than 40 years old. Nature and prognosis. Apropos of 41 surgically treated patients]

This study of 41 cases of young patients with obliterative arterial disease treated surgically, with follow-up for 6 and a half years, used the standard classification. Collection of the patients from a department of treatment falsified their true distribution. Atheroma was present in 90% of cases. Sixty eight per cent of patients were initially at stage II and 44% had a good long term result, essentially following the insertion of an aorto-bifemoral bypass. The mortality was 12%. The choice of surgical technique and ideal timing remain difficult to define. It would seem necessary to delay the date of the first operation for as long as possible, stressing the gravity of the first decision to operate.

[Obstructive calcification of the descending thoracic aorta and suprarenal abdominal aorta. 2 cases]

Two cases of obstructive calcification of the aorta treated by surgery are reported. The disease is extremely rare, notably in the aortic segments involved in these two cases. Its clinical features were similar to those of coarctation. Intraluminal proliferative calcifications were present in the descending thoracic aorta of the first patient who underwent aortic resection with Dacron replacement prosthesis and in the suprarenal segment of the abdominal aorta of the second patient for whom an extra-anatomical bypass between the ascending aorta and the upper abdominal aorta was performed. The first patients remains with moderate arterial hypertension after 4 years; arterial pressure returned to normal in the second patient and is still normal after 15 months.

Mitral valve replacement with St Jude Medical prosthesis. Incidence of thromboembolic events in 349 patients

This study reports incidence of thromboembolic episodes in a series of 349 patients where the St. Jude Medical (SJM) valve was implanted in the mitral position (252 isolated mitral, 91 mitral and aortic, 4 triple valve and 2 mitral and tricuspid valve replacements). The mean follow up was 28 months (range 6 to 57 months) which represents 784 patient-years. Overall operative mortality was 15 patients (4.3%). There were no valve-related deaths. Late post-operative prosthetic thrombosis occurred in 3 poorly anticoagulated patients (0.4% patient-years). A further 4 patients had a thromboembolic episode (0.5% patient-years). The overall frequency of thromboembolic episodes was 0.9 events per 100 patient-years. Per- and post-operative anticoagulation methods are described. The frequency of thromboembolism was studied with respect to the performance of SJM valve analyzed by echocardiography regardless the positioning of the prosthesis in the mitral ring. Our experience indicates that the SJM valve offers an excellent alternative in the choice of mechanical valve.

[Teratoma of the neck. A report of one case (author's transl)]

The authors present a rare case of teratoma developed in the cervical region of a female teenager. Comparing this case to the literature, they study the clinical aspects which are different according to the age of the discovery, pointing out the most frequent case of the newborn and they study the histological findings setting out the diagnosis. Prognosis depends on the maturity degree of the tissues; it is more often than not excellent after surgical exeresis with child contrary to the seldom adult cases of which the evolution is quickly distressing.