A comparison of low vs conventional-dose heparin for minimal cardiopulmonary bypass in coronary artery bypass grafting surgery.

The biocompatibility of minimal extracorporeal circuits has improved; however, anticoagulation is still required. We compared standard high-dose anticoagulation with a low-dose heparin regimen in a retrospective study of patients who underwent coronary bypass surgery using minimal cardiopulmonary bypass. One hundred patients who received 300 IU.kg(-1) heparin were compared with 68 patients who received heparin according to an individually adjusted activated coagulation time target of 300 s, resulting in a mean (SD) heparin dose of 145 (30) IU.kg(-1) . There were no thromboembolic events in either group; however, patients in the low-dose group had lower 24-hour mean (SD) postoperative blood loss than the conventional group (545 (61) vs 680 (88) ml, p=0.001) and a reduced rate of transfusion of allogeneic blood (15% patients transfused vs 32%, p=0.01). An individually tailored low-dose heparin regimen for minimal cardiopulmonary bypass is safe and may be associated with reduced bleeding and lower transfusion requirements.

[Large coronary aneurysm diagnosed during an acute coronary syndrome. A case report and review of the literature]. / Volumineux anévrisme coronaire découvert a l'occasion d'un syndrome coronaire aigu. A propos d'un cas et revue de la littérature.

Coronary aneurysm is an uncommon variant of coronary atherosclerosis. It usually involves the right coronary artery and is often associated with significant coronary stenosis. It may be revealed by an acute coronary syndrome (ACS). We report the case of a 49 year-old woman in whom a large coronary aneurysm of the left anterior descending artery was revealed by an ACS. Coronary angiography remains the gold standard diagnosis procedure, but spiral computed tomography may be of interest to specify the location and nature of the aneurysm, and thus guide surgical or percutaneous treatment.

[Cardiac surgery without transfusion in 2005]. / Chirurgie cardiaque sans transfusion en 2005. A propos d'une série de 200 témoins de Jehovah opérés.

PURPOSE: Between January 1991 and October 2003, 200 Jehovah Witnesses adult patients underwent elective cardiac surgery. To asses the impact on continuing progress of blood saving protocols and the increasing operative risk of patients proposed to surgery, we have re-assessed our results in this specific population. METHODOLOGY: Files of the first 100 patients operated upon between 1991 and 1998 were reviewed, and compared to the following 100 ones treated between 1998 to today. All patients were scored using the Euroscore model. RESULTS: In the latest series, patients are older (68 vs 51) and 13% underwent an iterative procedure, although there was none in the first series. Three deaths occurred after one month at the beginning of our experience, only one in the latest series. Operative risk factors had distinctly deteriorated, with more redux, and ejection fraction lower than 35%. Major progress to maintain morbi-mortality stability were multifactorial: preoperative erythropoietin in order to reach an haemoglobin minimal value of 14 g/dL, Cornell University protocol, mini-ECC, warm blood cardioplegia, ultra-early extubation. CONCLUSION: Cardiac surgery without transfusion can be realised with an equivalent risk to that of classical surgery, despite an operative risk aggravation, due to the association of recent conservative techniques.

End-systolic left ventricular pressure-dimension shift during acute relief of volume overload in the conscious dog.

To test whether left ventricular (LV) end-systolic dimensions are determined only by end-systolic pressure for a given inotropic state, 7 conscious dogs were studied during abrupt closure of a fistula created between the left subclavian artery and the left atrial appendage. The dogs were instrumented with an LV pressure micromanometer and ultrasonic crystals measuring LV major- and minor-axis diameters and ventricular wall thickness. During beta-blockade treatment and for the same end-systolic pressure, closure of the fistula produced a 40% decrease in cardiac output; end-diastolic diameter decreased by 1.5 mm and end-systolic diameter decreased by 0.9 mm. Calculated end-systolic volume was similarly decreased by 1.3 ml for a decrease of 2.9 ml of end-diastolic volume. Thus, large end-diastolic dimensional variations associated with peripheral resistance decrease significantly modify the end-systolic pressure-diameter (and volume) relations in the conscious animal. It is suggested that indexes obtained from these relations should not be used in patients when systolic pressure variations are associated with large stroke volume variations.

Natural history of saccular aneurysms of the left ventricle.

We have studied the natural history of left ventricular aneurysms (LVA) in 40 patients not treated surgically who were followed for a mean period of 5 years, 8 months. These patients have been divided into two groups according to the presence (Group B) or absence (Group A) of significant symptomatology. The causes of death are dominated by arrhythmias and congestive heart failure (CHF). The survival rate at 10 years is 66.7% for the entire group. In asymptomatic patients the 10 year survival rate is 90%, but it is only 46.3% in those who were symptomatic at the time of the initial diagnosis. In general, the clinical course of survivors is stable in Group A but has deteriorated steadily in Group B. Nonfatal complications include arrhythmias (observed in 34% of all patients), thromboembolic phenomena (29%), CHF (29%), and recurrent myocardial infarction (22.5%). Factors influencing prognosis are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, the left ventricular end-diastolic pressure (LVEDP), and the presence of ventricular extrasystoles at the time of diagnosis. The mere presence of aneurysm is not, in itself, an indication for operation. Incapacitating angina and refractory CHF are the most valuable indications for surgical resection. The question is raised as to the value of operation in patients with little or no symptoms, in those with isolated life-threatening arrhythmias, and in those in whom a mural thrombus is the only distressing feature.

Cor triatriatum and total anomalous pulmonary venous connection: a rare, surgically correctable anomaly.

Two cases of a very uncommon congenital association (cor triatriatum and total anomalous pulmonary venous connection) are presented. This association should be suspected in any infant with signs of pulmonary venous obstruction.

Intrauterine versus postnatal repair of created pulmonary artery stenosis in the lamb. Morphologic comparison.

Experimental lamb models were used for intrauterine creation of pulmonary artery stenosis and later intrauterine repair or postnatal repair. Intrauterine creation of pulmonary artery stenosis was performed in 23 fetal lambs at 90 +/- 1 days of gestation. Eight lambs underwent intrauterine repair of pulmonary artery stenosis at 135 +/- 1 days of gestation and were studied 110 +/- 13 days after repair. Seven lambs underwent postnatal repair at 57 +/- 9 days after birth and were studied 162 +/- 32 days after repair. Eight fetal lambs with unrepaired pulmonary artery stenosis were studied 89 +/- 18 days after birth. All study lambs were compared with normal control lambs. The systolic right ventricular pressure was significantly higher after unrepaired stenosis (78.6 +/- 6.8 mm Hg) than in other lambs, but there was no statistically significant difference after intrauterine repair (23.3 +/- 2.9 mm Hg), postnatal repair (25.9 +/- 3.4 mm Hg), and normal lambs (21.6 +/- 1.1 mm Hg). The systolic pulmonary artery pressure was also not statistically different in these three groups. The weight measurements were age-adjusted for comparison of postnatal and intrauterine repair with normal lambs. The adjusted heart weights were similar in the three groups. The comparison of the adjusted heart weight/adjusted body weight ratio (10(-3) showed a significantly higher ratio in postnatal repair (7.4 +/- 0.1) than in intrauterine repair (6.1 +/- 0.1). The adjusted right ventricular weight/adjusted left ventricular weight ratio was significantly higher in the postnatal repair group (0.71 +/- 0.01) than in both the intrauterine repair group (0.59 +/- 0.01) and normal lambs (0.59 +/- 0.01). The transverse myocyte diameter was not statistically different in all groups of animals and there were no ultrastructural changes even when the pulmonary stenosis was unrepaired. We conclude that intrauterine repair was more satisfactory than postnatal repair in terms of age-adjusted heart weight results, but we did not find any advantages of intrauterine repair in terms of histologic and ultrastructural changes.

Intrauterine creation and repair of pulmonary artery stenosis in the fetal lamb. Weight and ultrastructural changes of the ventricles.

Fetal lamb experimental models were employed for intrauterine creation and repair of pulmonary artery stenosis. The study group was composed of 51 fetal lambs including 29 models of pulmonary artery stenosis and 22 control lambs. Gestational age was 89 days at creation of pulmonary artery stenosis. Fourteen fetal lambs (Group A) were studied after creation of the stenosis at 131 days of gestation and compared to normal age-matched control lambs. The systolic right ventricular pressure was significantly higher after creation of pulmonary artery stenosis (76.6 +/- 17.8 versus 50.3 +/- 23.5 mm Hg), but the systolic pulmonary artery pressure was unchanged. The mean right ventricular weight and the mean right ventricular/left ventricular weight ratio were significantly greater after pulmonary artery stenosis than in normal control animals. The transverse myocyte diameter was not modified by pulmonary artery stenosis, but on electron microscopic study the myocytes appeared mature. Ten lambs (Group B) underwent intrauterine repair of pulmonary artery stenosis at 131 days of gestation without cardiopulmonary bypass. The pulmonary artery was clamped and patched. Immediately after repair the right ventricular pressure fell significantly from 85.8 +/- 18.9 to 62.2 +/- 14.6 mm Hg. At birth, 7 +/- 6 days after repair, Group B was compared to Group C (unrepaired pulmonary artery stenosis, five fetuses) and to normal control lambs. The mean right ventricular weight and the mean right ventricular/left ventricular weight ratio were not statistically different in Group B and in the control group. There were no ultrastructural changes after intrauterine repair. We conclude that intrauterine creation of pulmonary artery stenosis causes right ventricular hypertrophy with more mature myocytes. Intrauterine repair of pulmonary artery stenosis is feasible without cardiopulmonary bypass and rapidly abolishes the preponderance of right ventricular weight over left ventricular weight.

Experimental evaluation of porcine-valved conduits processed with a calcium-retarding agent (T6).

The effectiveness of a water-soluble C-12 alkyl sulfate (T6) (U.S. Patent No. 4,323,358) in retarding bioprosthetic calcification was evaluated in 23 porcine-valved conduits (13 T6-treated conduits and 10 controls) implanted in young sheep between the right ventricle and the pulmonary trunk. The grafts were divided into three groups according to the period of function: Group I, less than 2 months; Group II, 2 to 4 months; and Group III, 5 to 7 months. In Group I (four T6 and four controls), endocarditis occurred in five cases. In Group II (three T6 and three controls), four conduits showed severe fibrous peel ingrowth. In Group III (six T6 and three controls), fibrous peel was the main feature in four conduits and calcium deposits occurred in the porcine aortic wall in all cases, with cusp involvement in two; in both T6-treated and control conduits, chemical analysis showed a much lower calcium content of the cusps (8.45 +/- 80 versus 2.95 +/- 1.52 mg/gm dry weight, respectively) than that reported in other animal or human explants. The grade of calcification in control and T6-treated conduits was equal on x-ray analysis, and no differences in calcification patterns were noted on electron microscopy. This experimental model shows a low degree of cusp calcification and no significant differences between T6-treated and control conduits. Peel formation markedly interferes with performance of the porcine-valved conduit. The results of this analysis indicate that valved conduits are not the optimum model for evaluating calcium-retardant agents in biological valves.

Use of biological glue in acute aortic dissection. Preliminary clinical results with a new surgical technique.

Use of a biological glue (GRF) is common in certain fields such as hepatic or renal surgery, but its use in vascular surgery, especially in acute aortic dissection, has not yet been reported. Our experience has demonstrated many advantages: The glue is very simple and safe to use. The aortic tissues are firmly reinforced and the sutures tighten immediately. The proximal aortic stump is anatomically reconstructed, and generally the aortic valve can be preserved and coronary reimplantation avoided. The preoperative and postoperative bleeding rates are low and the postoperative course generally is simple. The risk of maintenance or recurrence of the dissection process is reduced. Consequently, the hospital mortality rate can be reduced to about 10 percent and the long-term survival rate greatly improved.

Surgical treatment of multiple ventricular septal defects using a biologic glue.

The closure of multiple ventricular septal defects remains a surgical challenge. Mortality and morbidity are high. Left ventricular incision and multiple patches or stitches impair septal motion and function. We searched for a method that would cause minimal left ventricular and septal dysfunction. The use of fibrin seal for closing ventricular septal defects was considered. The method was first tested in animals so as to assess the internal resistance of the fibrin seal to stretching and fragmentation in addition to its adhesiveness and hence the absence of left-to-right embolization of the fibrin seal clot and the long-term success of the ventricular septal defect closure further to complete resorption of the ventricular septal defect clot. This experimental work was very satisfactory. Between April 1986 and September 1991, 15 children were operated on with the use of this technique. The overall hospital mortality rate was 6%. There were no reoperations for residual ventricular septal defects. All the long-term survivors (n = 13) were in excellent clinical condition with no or trivial residual shunt attested by color flow mapping investigation. This experimental and clinical experience suggests that satisfactory results can be achieved with the use of fibrin seal for the closure of multiple muscular ventricular septal defects.

Aortocoronary bypass with homologous saphenous vein: long-term results.

Between February 1973, and February, 1979, 27 homologous saphenous veins were used in 20 patients (mean age, 54 years). Seven fresh grafts were used less than 24 hours after severance. They were kept at a temperature of 4 degrees C in saline solution containing penicillin. Twenty cryopreserved grafts were used within a period of eight days to 2 months from severance. They were preserved in glycerol at a temperature of -40 degrees C. One patient (5%) died postoperatively. A perioperative myocardial infarction developed in 3 patients (15%). Average follow-up is 27 months. No late mortality was registered. Fifteen patients are free from symptoms, and 3 patients have residual angina with exercise. Control angiograms were made in 13 patients 1 to 68 months after operation; 17 homografts were seen. Early occlusion of 1 graft and late occlusion of 8 grafts were registered. The poor late patency rate does not seem to be related to either histocompatibility or technical conditions. Conversely, microscopic examination of several cryopreserved grafts showed that the mode of preservation resulted in deterioration of intimal and medial tissues of the vein. Therefore, it appears to us that the use of homologous saphenous veins should be avoided for coronary bypass.

"Classic" repair of congenitally corrected transposition and ventricular septal defect.

BACKGROUND: This study examined the results of "classic" repair of congenitally corrected transposition of the great arteries and ventricular septal defect. METHODS: From 1974 to 1994, 52 patients underwent a classic complete repair of lesions associated with congenitally corrected transposition. They were divided into two groups: ventricular septal defect plus left ventricular outflow tract obstruction (group I, 37 patients) and isolated ventricular septal defect (group II, 15 patients). Tricuspid plasty or replacement was performed primarily in 1 patient of group I (3%) and in 8 patients of group II (53%). RESULTS: The overall operative mortality was 15% (8/52 patients), and the incidence of postoperative atrioventricular block was 27% (14/52 patients). Eight patients died secondarily, 5 of heart failure. Survival rates were 83% +/- 6% at 1 year and 55% +/- 14% at 10 years for group I and 86% +/- 9% at 1 year and 71% +/- 12% at 10 years for group II (not significant). Redo tricuspid plasty or replacement was performed in 12 patients. CONCLUSIONS: Results of classic complete repair of lesions associated with congenitally corrected transposition are not satisfactory in our experience because (1) the operative mortality and the incidences of tricuspid valve replacement and atrioventricular block are high and (2) secondary heart failure is frequent. However, a retrospective review of morphologic findings shows that "anatomic" complete repairs would not have been feasible in 6 of our patients.

Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients?

BACKGROUND: The purpose of this study was to determine whether, with appropriate techniques, diabetic patients could benefit from the advantages of double internal thoracic artery (ITA) coronary bypass without an increased hospital risk. METHODS: Between January 1990 and December 1996, 207 consecutive diabetic patients underwent coronary artery bypass graft operations. In 74 patients both arteries (bilateral ITA group) were used, whereas 133 patients received one ITA and vein grafts or vein grafts alone (nonbilateral group). Patients in the bilateral ITA group were younger (p<0.0001), predominantly male (p<0.0001), and were operated on more electively. The internal thoracic arteries were harvested by skeletonization without electrocautery, and strict glycemic control was pursued. RESULTS: No death was observed in the bilateral ITA group, whereas 7 patients died in the nonbilateral ITA group (p<0.05). Deep sternal wound infection was observed in 2 patients in the nonbilateral ITA group (1.5%) and in none of the bilateral ITA group (p = NS). There was no significant difference in the morbidity rate between the two groups except for greater blood losses in the bilateral ITA group. CONCLUSION: Double ITA coronary revascularization in young diabetic patients was performed without increased morbidity and mortality. The low rate of sternal wound infections may be related to ITA harvesting by a skeletonization technique, but larger studies are required to confirm these data.

Effects of two different crystalloid cardioplegic solutions assessed by myocardial pH, tissue lactate content and energy metabolism.

OBJECTIVE: The influence of composition of crystalloid cardioplegia is imprecise in clinical practice. Therefore, we investigated changes in intramyocardial pH, tissue lactate content and energy metabolism during cardioplegic arrest with 2 different crystalloid cardioplegic solutions. METHODS: Twenty patients were randomly allocated to 2 groups: 10 patients had crystalloid cardioplegia buffered with bicarbonate (neutral pH of 7.8 at 20 degrees) with no additives (St Thomas' II solution) and 10 patients had a non buffered crystalloid cardioplegia (mildly acidic pH of 7.4 at 20 degrees) enriched with glutamate and mannitol (Menasché's solution). Tissue lactate and energy metabolism were measured on myocardial biopsy specimens and intramyocardial pH were continuously measured during cardioplegic arrest by a miniature glass electrode. RESULTS: There were no statistical differences in hemodynamic results and in AMP, ADP, ATP, lactate values measured on biopsy specimens. The curves of intramyocardial pH were very similar in the 2 groups, the median values were 7.42 +/- 0.1 in group 1 and 7.41 +/- 0.1 in group 2 (temperature corrected values) and the areas under the curves were 260 +/- 4 and 259 +/- 4 in groups 1 and 2 respectively (P = NS). CONCLUSIONS: Glutamate provided no additive metabolic myocardial protection, bicarbonate had a weak buffering capacity in cold cardioplegic solutions and the 2 studied crystalloid solutions warranted a good myocardial protection in clinical practice.

Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients.

OBJECTIVE: To test the hypothesis that the skeletonized technique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. METHODS: Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6 +/- 0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9 +/- 8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. RESULTS: Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 +/- 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. CONCLUSION: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.

Traumatic rupture of the thoracic aorta with reference to 34 operated cases.

34 cases of traumatic rupture of the aortic isthmus have been operated on since 1963: 14 acute ruptures and 20 secondary false aneurysms. Diagnosis was confirmed by aortography. A special feature seen in cases of total transsection is described. Partial extracorporeal bypass was used in 29 cases and direct cross-clamping in 5 cases. Two techniques were used: direct end-to-end anastomosis in 9 patients and Dacron graft interposition in 25 cases. Primary end-to-end anastomosis more often was used in cases of early operation and partial rupture. Hospital mortality was 2 patients in the group of acute ruptures and 0 patient in chronic false aneurysm group. It was related to brain damage or sequelae of prolonged shock. Post-operative course was uneventful but 4 cases of respiratory failure and 4 cases of neurologic disturbances (2 brain dysfunctions and 2 spinal cord dysfunctions). These complications were transient and the patients recovered without sequelae. Clinical results have been recently appreciated in every long-term survivor (mean follow-up: 5 years) and are excellent. Angiographic controls undergone in 10 patients have shown no abnormalities.

Fibromuscular dysplasia causing atypical coarctation of the thoracic aorta: histological presentation of a case.

The authors report a case of atypical coarctation of the thoracic aorta discovered by chance in a 37-year-old man, victim of a car accident. The angiogram revealed a "string-of-beads" contour in the coarctate area while the left subclavian artery presented a severe stenosis at its origin. Vascular checkup examination failed to identify any additional vascular anomaly. The patient underwent surgical resection, with a Dacron prosthetic bypass. Histological study of the specimen removed, showed a typical perimedial and extensive medial types of fibromuscular dysplasia (FMD) of the aorta. Pathogenesis of this disease is discussed.

[Evaluation of 90 normal aortic valve prosthesis of the Saint-Jude Medical type by echocardiography]. / Evaluation par échocardiographie doppler de 90 prothèses valvulaires aortiques normales de type Saint-Jude Medical.

Between September 1986 and February 1989, ninety patients undergoing isolated aortic valve replacement were studied on the 15th postoperative day, in the Department of Cardiac Surgery at St Joseph's Hospital, Paris. Patients with a diastolic murmur, fever, significant, pericordial effusions and poor quality Doppler recordings were excluded. The aim of the study was to determine normal Doppler echocardiographic parameters of St Jude medical aortic valve prostheses. Maximum and mean transprosthetic pressure gradients were calculated by the simplified Bernoulli equation. Functional value surface area was assessed by the continuity equation using the diameter of the left ventricular output tract measured by 2D echocardiography (continuity) and the external diameter of the prostheses (modified surface area) to calculate the subaortic surface area. The transprosthetic pressure gradients G max and G mean were inversely correlated to the size of the prostheses (r = 0.42 and r = 0.45). The functional valve surface area calculated by the continuity method gave a poor correlation but this improved considerably when the diameter of the prosthesis (modified surface area) was considered. Finally, the permeability index which is the ratio of subaortic and transaortic velocities seemed to be a good parameter for assessing prosthetic valve function.

[Value and indication of the use of 2 internal mammary arteries in repeated coronary surgery]. / Intérêt et indication de l'utilisation des 2 artères mammaires internes dans la chirurgie coronaire redux.

Forty-nine patients who had coronary artery reoperations were divided into two groups: the 29 patients of the first group were operated conventionally with use of one internal mammary artery or a saphenous vein; the 20 patients of the second group were reoperated using both internal mammary arteries. Three patients (6%) died prematurely: two in the first and one in the second group. The rates of peri-operative infarction were 7% and 15% respectively. The average postoperative bleeding was 472 +/- 385 ml in the first group and 700 +/- 628 ml in the second group (NS). All patients are pauci-symptomatic and have a negative exercise stress test. The mortality and morbidity of coronary reoperation does not seem to be greater with double internal mammary artery bypass grafting. However, this technique should be reserved for patients who can derive long-term benefit from reoperation with arterial grafts, that is to say in patients in good clinical condition, less than 65 years of age with good left ventricular function. In these patients, double internal mammary artery bypass grafting may avoid a third operation for myocardial revascularisation.