[Long term evolution of chronic constrictive pericarditis. A study of 56 patients]. / Evolution a long terme des péricardites constrictives chroniques. A propos de 56 patients.

OBJECTIVE AND METHOD: We retrospectively analysed 56 consecutive patients with a confirmed diagnosis of chronic constrictive pericarditis over a period of 23 years. The objective was to analyse the evolution of the annual frequency of constrictive pericarditis, its aetiology and to define the prognostic factors for mortality. RESULTS: The annual frequency of constrictive pericarditis has not diminished over the 23 years of this study, remaining at 2.4 cases per year. Cases with a tuberculous origin have diminished progressively, being replaced by complications of cardiac surgery and mediastinal radiotherapy. Pericardectomy was performed in 41 patients and the average follow up was 9.5 +/- 8.6 years. By the end of the study, 34 patients had died (61.8%), 18 from a cardiovascular cause (38.3%). The independent predictive factors for overall mortality were a history of mediastinal radiotherapy, the age, and plasma sodium level. Only the presence of first degree atrio-ventricular block was an independent predictive factor for cardiovascular mortality. In the pericardectomy group, 24 patients died (60%). A history of mediastinal radiotherapy and the presence of pre-operative hyponatraemia were independent predictive factors for overall mortality. CONCLUSION: Constrictive pericarditis remains a serious pathology. Pericardectomy allows a clear functional improvement, but following pericardectomy more than 60% of patients will die within 10 years of the diagnosis being made.

The CarboMedics 'Top-Hat' aortic valve prosthesis: short-term results.

BACKGROUND AND AIM OF THE STUDY: The CarboMedics 'Top-Hat' aortic valve prosthesis has been specifically designed for supra-annular implantation. The aim of this study was to assess the safety of implantation of this prosthesis by reporting the short-term results of follow up. METHODS: Between May 1993 and May 1998, 128 patients (mean age 62.5 +/- 9.8 years; range: 22-76 years) received a CarboMedics 'Top-Hat' prosthesis at our institution. Among patients, 55% were in NYHA functional classes III or IV, and 54.7% had an isolated aortic valve replacement. Associated procedures were: coronary artery bypass grafting (25.7%), double valve replacement (17.1%), treatment of ascending aortic aneurysm (4.7%) and miscellaneous (5.5%). Follow up was 100% complete; total cumulative follow up was 265 patient-years (pt-yr) (range: 2-60 months). RESULTS: The overall mortality rate was 1.5% (two deaths). The operative mortality rate was 0.8% (one death); this patient died from neurological complications after operation for aortic dissection. The other patient died on postoperative day 40 from a massive cerebral hemorrhage. Four patients presented thromboembolic events; in all cases these were reversible ischemic neurologic deficits. One patient had a nonstructural deterioration (endocarditis) and required reoperation. Freedom from mortality was 98.3% at five years (linearized rate of 0.75%/pt-yr). Freedom from thromboembolism was 63.1% at five years (linearized rate 1.5%/pt-yr). CONCLUSION: Short-term results with the CarboMedics 'Top-Hat' prosthesis were satisfactory, with low rates of morbidity and mortality. As this prosthesis has demonstrated a good reliability to date, we have continued its implantation in our institution, and long-term follow up will be necessary to confirm these good early results.

Airway compression in children due to congenital heart disease: value of flexible fiberoptic bronchoscopic assessment.

OBJECTIVE: To evaluate the frequency and severity of airway compression due to congenital heart disease in children and validate the use of the fiberoptic bronchoscope to assess them. DESIGN: A retrospective study. SETTING: A single-institutional study in a university hospital. PARTICIPANTS: Seventy-two children with congenital heart disease. INTERVENTIONS: Airway endoscopy was performed in an awake child in cases of clinical and/or radiologic respiratory signs or in cases of preoperative assessment of a cardiac abnormality that is known to accompany airway compression. MEASUREMENTS AND MAIN RESULTS: Endoscopy was well tolerated; 71% of the children had endoscopic abnormalities and 50% had airway compression. The locations of these compressions are the same as those described in the literature in the cases of vascular rings and left-to-right shunts. The other endoscopic findings were laryngeal and bronchial abnormalities, tracheobronchial malacia, respiratory signs of gastroesophageal reflux, and positive bacteriologic sputum samples. CONCLUSION: Endoscopy in an awake patient is the only way to evaluate the functional component of a compression due to malacia; the resulting collapse of the airway can cause trapping of air and secretions. Furthermore, fiberoptic bronchoscopy offers a complete examination of the airways and can help detect airway abnormalities that are potential causes of complications. Fiberoptic bronchoscopy is a suitable and well-tolerated examination that is easy to perform at the bedside of the child. This technique optimizes the preoperative assessment of children with congenital heart disease.

Calf vein compliance increases following bed rest after aortocoronary bypass surgery.

Early post-operative ambulation (< 3 days) is expected to decrease the risk of venous thrombosis, whereas late ambulation (> 7 days) increases the risk of orthostatic hypotension. The effect of post-operative bed rest on calf vein compliance was studied before (D - 1) and 7 days (D + 7) after aortocoronary bypass surgery in 50 patients (41 men and nine women, 65 +/- SD 10 years). Calf vein compliance was measured by strain gauge plethysmography and stepwise increases in thigh congestive pressure from 20 to 60 mmHg. Calf compliance [median (25 percentile-75 percentile)] increased significantly by 48% from D - 1 to D + 7 [0.044 (0.039-0.051) vs. 0.065 (0.048-0.083) ml (100 ml mmHg)-1, P < 0.001]. This increase was reflected as increased calf volume for the 50 mmHg [D-1 2.10 (1.75-2.65) vs. D + 7 2.60 (1.70-3.00) ml 100 ml-1, P < 0.01] and 60 mmHg [D - 1 2.50 (2.10-2.95) vs. D + 7 3.20 (2.30-4.00) ml 100 ml-1, P < 0.001] occlusion pressure levels. The associated pathologies (diabetes and arterial hypertension) and NYHA grades had no significant influence on the increase in compliance. Among the vasoactive therapeutic regimens, calcium channel blockers contributed significantly to the increased calf compliance, but only on D-1. The increase in venous compliance following aortocoronary bypass surgery is multifactorial but should be considered for prophylactic management of these patients.

Doppler-echocardiographic assessment of the carbomedics supra-annular 'Top-Hat' prosthetic heart valve in the aortic position.

Twenty-one CarboMedics 'Top-Hat' bileaflet prostheses were implanted in the aortic position between May 1993 and May 1994 at our institution. Valve performance was assessed by repeat echocardiography. We found it very easy to implant this prosthesis even in the small aortic annulus and it allowed us to implant a valve that is at least one size larger than implantation in the intra-annular position allows. The only contraindication to the implantation of this prosthesis is when the coronary ostia are displaced downwards, which would apply to any supra-annular prosthesis. The Doppler echocardiographic assessment showed acceptable transvalvular gradients and velocity indexes. The Top-Hat prosthesis is now our valve of choice in the small aortic annulus.

Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain.

BACKGROUND: Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the brain, especially when the internal jugular vein is valvulated (88% of the cases). This anatomic study was carried out to determine how a liquid injected in the superior vena cava reaches the brain. METHODS: Three groups of adult cadavers (5, 5, and 3 cases, respectively) were injected with latex, colored blue, through a cannula in the superior vena cava. In group I, 600 mL of latex was injected. Group II was identical except that a catheter had been inserted, before the injection, into the internal jugular vein to collapse the internal jugular vein valve, when existing. In group III, the azygos vein was ligated. RESULTS: The internal jugular vein was not valvulated in 2 cases in group I. In those 2 cases, latex was found up to the jugular foramen. In the other cases in group I, and in all cases in group II, where the internal jugular vein was valvulated, the following veins were injected: internal jugular vein up to the valve (almost no latex beyond), azygos vein, inferior vena cava, renal veins, rachidian and perimedullar venous plexuses, and venous sinuses of the brain. In group III, no opacification was observed beyond ligated azygos vein or valvulated internal jugular vein. CONCLUSIONS: Despite the fact that this study was carried out on cadavers, one can assume that, during retrograde cerebral perfusion, the azygos vein system is a major way to the central nervous system when the internal jugular vein is valvulated.

[Angiographic study of collateral circulation in coronary occlusion]. / Etude angiographique de la circulation de suppléance au cours des occlusions coronaires.

To define the collateral circulation pathways between coronary arteries, 101 coronarographies of patients who had at least one occlusion of a coronary artery (left-anterior descending artery, circumflex, right coronary) were analysed. We found 12 collateral pathways for the right coronary, 8 for the anterior descending artery, and 4 for the circumflex artery. These collateral circulation pathways have been mapped and compared to those of literature.

[Comparison of effects of aprotinin and tranexamic acid on blood loss in heart surgery]. / Comparaison des effets de l'aprotinine et de l'acide tranexamique sur le saignement en chirurgie cardiaque.

OBJECTIVES: To compare the efficacy of aprotinin (APR) and tranexamic acid (TRA) in reducing blood loss and transfusion requirements after cardiac surgery under extracorporeal circulation (ECC). STUDY DESIGN: Randomized controlled trial. PATIENTS: One hundred and four adults undergoing either coronary artery bypass grafting (CABG) (n = 55), or aortic valve replacement (AVR) (n = 49), allocated into three groups. METHODS: a) APR group (23 CABG and 20 AVR) received aprotinin, 2 x 10(6) KIU (280 mg) after induction, followed by an infusion of 0.5 x 106 KIU.h-1 (70 mg.h-1) until chest closure, with a supplement to the oxygenator prime of 2 x 10(6) KIU; b) TRA group (22 CABG and 19 AVR) received tranexamic acid, 15 mg.kg-1 between the injection of heparin (400 IU.kg-1) and the beginning of ECC, 15 mg.kg-1 after protamin injection (1.3 mg/100 IU of heparin); c) CTR group (10 CABG and 10 AVR), the control group, was not treated with an antifibrinolytic agent. The amount of blood collected from the chest tube drainage was measured at admission to ICU, as well as 4, 8 and 18 h after the insertion of drains and at the time of their removal. Packed red cells where given when the haematocrit was under 20% during ECC, 25% at the end of surgery and 30% after extubation. RESULTS: The blood loss was lower in APR group (834 +/- 448 mL) than in TRA group (1015 +/- 409 mL) (P = 0.009), and in CTR group (1416 +/- 559 ML) (P = 0.004). The rates of transfused patients in groups APR, ATR and CTR were 35, 37 and 60% respectively and the numbers of units administered per patient were 0.8, 0.8 and 1.7 respectively. In AVR cases, APR and TRA had a similar efficacy. In CABG cases, only aprotinin decreased postoperative bleeding. However there was no difference between APR and TRA concerning the transfusion requirements. In CABG cases the ECC was of shorter duration and blood loss was 1127 +/- 540 mL vs 894 +/- 422 mL in AVR cases (P = 0.03). CONCLUSIONS: Both APR and TRA decrease blood loss. APR is more efficient after CABG than TRA as far as blood loss is concerned, whereas the transfusion requirements are similar. As APR is about 100 times more expensive and carries a risk for allergic reactions, its use in a high dose regimen is only recommended for reoperations, in patients treated with salicylates and in case of sepsis.

[Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age]. / Chirurgie cardiaque chez les patients âgés; résultats immédiats et à moyen terme chez 100 patients âgés de 75 ans et plus.

With improved operative technique and postoperative care, progressively older patients are being referred for cardiac surgery. One hundred out of 633 patients operated between September 1990 and December 1992, were over 75 years of age (Group I). These patients were compared with the last 100 patients under 75 years of age (Group II). Both groups were operated by the same surgical team with the same anaesthetic, cardiopulmonary bypass and myocardial protection techniques. The average age of the groups was 79.5 +/- 3.1 and 62.1 +/- 9.2 years, respectively. The procedures performed were: myocardial revascularisation (Group I, 28 cases; Group II, 59 cases), aortic valve surgery alone or associated with coronary bypass (56 and 22 cases respectively), and mitral valve surgery alone or associated with another procedure (11 and 12 cases). There were no significant differences between the two groups with respect to true low output state, the duration of mechanical ventilation and of intensive care and hospital stay. On the other hand, there were significant differences in: the number of blood transfusions (44 cases versus 20, p < 0.001), the occurrence of atrial fibrillation (52 cases versus 29, p < 0.001) and neuropsychiatric disturbances (27 cases versus 5, p < 0.0001). There were no cases of mediastinitis in either group. The hospital mortality was 6% in Group I and 5% in Group II (NS). The medium-term mortality after an interval of 5 to 32 months in the over 75 age group was 7 cases, including 4 cases of cerebrovascular accident. An enquiry was performed in the 87 survivors of Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retrograde cerebral perfusion for replacement of the aortic arch. Apropos of a case]. / Perfusion cérébrale rétrograde pour remplacement de la crosse aortique. A propos d'un cas.

The authors report a case of cerebral protection with retrograde cerebral perfusion during aortic arch surgery. The duration of retrograde cerebral perfusion and the favorable neurological outcome seem to confirm the promising results of this technique developed in Japan.

[Long-term retrograde cerebral perfusion in surgery of the aortic arch. Apropos of 2 cases]. / Perfusion cérébrale rétrograde de longue durée dans la chirurgie de la crosse aortique. A propos de deux cas.

The authors present two cases of aortic arch replacement for aortic dissection: one in a male patient 58 years old and the other in a female patient 78 years old. Cerebral protection during repair of the aortic arch was performed with retrograde cerebral perfusion (RCP). Durations of RCP were 75 and 120 minutes respectively. Good neurological recovery in both patients appeared to confirm the efficacy of RCP with respect to cerebral protection during surgery of the aortic arch.

[Macroscopic vascularization of the adult sternum. Implications of removal of the internal thoracic arteries]. / Vascularisation macroscopique du sternum adulte. Implications du prélèvement des artères thoraciques internes.

The most of the arterial vascularisation of the adult sternum is on the dependence of the internal thoracic arteries. The best results of the aorto-coronary by-pass starting from this arteries are however subjected to more infectious complications. The study of this arterial supply, in "surgical" conditions, after sternotomy and ablation of one or two internal thoracic arteries show this devascularization. The residual arterial supply is only constituted by thin branches coming from intercostal arteries.

Is the internal mammary artery an acceptable graft in the elderly patients with left main coronary artery disease?

Age over 70 years and critical stenosis of the left main coronary artery trunk are two situations in which the use of the internal mammary artery has been questioned. Because the coexistence of these two conditions is increasingly seen, we reviewed our experience with 53 patients 70 years of age or older that underwent myocardial revascularization for left main disease. In 17 patients, the left anterior descending coronary artery was grafted with the left internal mammary artery whereas the 36 remaining patients were exclusively revascularized by means of saphenous vein conduits. There was no significant difference in postoperative mortality or morbidity between the two patient groups. We conclude that elderly patients with left main disease should be offered the benefits of a mammary artery graft provided they are hemodynamically stable.

[Retrograde cardioplegia through the coronary sinus in the surgery of the aortic valve. A clinical study of 500 patients]. / La cardioplégie rétrograde par le sinus coronaire au cours de la chirurgie de la valve aortique. Etude clinique de 500 patients.

Over the last few years there has been a renewal of interest in retrograde administration of cardioplegic solutions but this method has not been validated by a large scale clinical trial. From 1980 to 1989 our group used retrograde coronary sinus perfusion as the only means of administering cardioplegia in 500 consecutive patients undergoing isolated aortic valve replacement (AVR) (359 cases) or associated with another valvular or myocardial revascularization procedure (141 cases). Using this method, there were 31 hospital deaths (6.2%) of which 20 were of cardiac origin (4%). During the last 5 years, hospital mortality for isolated AVR decreased to 1.5%. With an incidence of low cardiac output of 12%, of arrhythmias and atrioventricular block of 7.4% and 1.2% respectively, and of myocardial infarction of 1.4%, this method of cardioplegia compares favourably with anterograde perfusion. There were only 3 traumatic lesions of the coronary sinus, all occurring at the beginning of the series and all of which were successfully repaired. Retrograde coronary sinus perfusion is therefore a safe and effective method of cardioplegia during aortic valve surgery: the cardioplegic solution is distributed uniformly in patients with coronary artery disease and therefore, this could become the technique of choice for myocardial protection in coronary artery or mixed coronary and valvular surgery.

[Interrupted aortic arch. A series of 15 patients]. / Interruption de l'arche aortique. Une série de 15 patients.

Between 1983 and 1989, 15 children underwent surgical repair of interrupted aortic arch at 1 to 20 days of age. The anatomical form was a Celoria and Patton type B in all patients with an associated perimembranous ventricular septal defect in all but one who had multiple ventricular septal defects, and patent ductus arteriosus. Six children had a retro-esophageal right subclavian artery, two had subaortic stenosis and two had a right-sided descending thoracic aorta. In two children with severe hypoplasia of the ascending aorta the repair was performed in one stage with two deaths due to left ventricular failure. In the other B cases, a two-stage repair was carried out. The reconstruction of the aortic arch varied according to the individual case. All children had pulmonary artery banding. Seven children survived longer than 30 days. Six of them later underwent a complete repair. The only survivors were those patients in whom the neo-aortic arch grew harmoniously. The authors conclude that: a two-stage repair gave disappointing results in this series of consecutive patients, mainly because of the poor quality of the reconstruction of the aortic arch by thoracotomy.

Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions.

Myocardial areas distal to complete coronary artery occlusions are poorly protected by antegrade cardioplegia. We assessed the effects of coronary sinus cardioplegia in 30 patients undergoing bypass operations and at high risk of cardioplegic maldistribution because of the following anatomical patterns of coronary artery disease: critical (greater than or equal to 50%) stenosis of the left main trunk with total occlusion of the right coronary artery (16 patients) or critical (greater than or equal to 70%) stenosis of the right coronary artery with total occlusion of the left anterior descending (11 patients) or circumflex artery (3 patients). After induction of arrest through the aorta, coronary sinus cardioplegia was given intermittently during the cross-clamp period at a flow rate of 100 mL/min. Intraoperatively, occluded arteries were consistently found to be filled with the retrogradely infused solution. One patient died early postoperatively of low cardiac output and a second patient died later during his hospital stay, presumably of an arrhythmia. At autopsy, none of them had pathological evidence of inadequate myocardial protection. One patient sustained a myocardial infarction and 3 others required inotropes for more than 24 hours postoperatively. Postoperative values for right and left stroke volume indices were not significantly different from prebypass levels. Overall, these results are consistent with the occurrence of limited intraoperative ischemic damage and, by inference, suggest the efficacy of the coronary sinus route in preserving myocardial areas supplied by completely occluded coronary arteries and, hence, in jeopardy of inadequate cardioplegia delivery.

Retrograde coronary sinus cardioplegia for aortic valve operations: a clinical report on 500 patients.

Retrograde delivery of cardioplegic solutions has recently been the subject of renewed interest, but the reliability of this technique has not been assessed in large clinical series. From 1980 to 1989, we used retrograde coronary sinus perfusion as the exclusive means of cardioplegia delivery in 500 consecutive patients undergoing aortic valve replacement, either isolated (359 patients) or combined with another valve or coronary procedure (141 patients). The coronary sinus was always cannulated under direct vision after bicaval cannulation with snaring. Cold crystalloid cardioplegia was delivered retrogradely at an average flow rate of 100 mL/min in conjunction with topical and systemic (25 degrees C) hypothermia. The mean cross-clamp time was 83 +/- 23 minutes (+/- the standard deviation). There were 31 hospital deaths (6.2%), 20 of which were cardiac related. Transient hemodynamic instability (defined as a need for inotropic agents for less than 24 hours postoperatively) occurred in 16 patients (3.2%), whereas a true low-output syndrome developed in 60 patients (12%). The incidence of clinically significant supraventricular arrhythmias and of permanent conduction defects was 7.4% and 1.2%, respectively. There were three nonfatal coronary venous injuries during our early experience. We conclude that coronary sinus perfusion is a safe and effective means of delivering cardioplegia in aortic valve operations. While providing a degree of myocardial protection similar to that reported with anterograde cardioplegia, the coronary sinus technique offers distinct advantages, in particular, the avoidance of perfusion-related coronary artery complications and the opportunity to repeat cardioplegia administration without interrupting the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adequate preservation of right ventricular function after coronary sinus cardioplegia. A clinical study.

Whether retrograde coronary sinus cardioplegia adequately preserves right ventricular (RV) function is still a point of concern. Using technetium Tc 99m-labeled red blood cells, we assessed global and segmental RV function by first-pass and gated blood-pool radionuclide angiocardiography before and within 24 hours after aortic valve replacement in 14 consecutive patients (age, 58 +/- 5 years; mean +/- SEM). Coronary sinus cardioplegia was given in a multidose fashion at a flow rate of 50-70 ml/min through a balloon-tipped catheter, with the inflated balloon kept seated around the intra-atrial rim of the coronary sinus orifice. Additional myocardial protection was provided by systemic (25 degrees C) and topical hypothermia. Postoperatively, none of the patients had clinical or hemodynamic patterns suggestive of RV dysfunction. The postoperative global RV ejection fraction (0.49 +/- 0.03) was similar to the preoperative value (0.49 +/- 0.01). Analysis of segmental wall motion did not reveal postoperative abnormalities of new onset in any of the three anatomically defined RV regions (free wall, apex, and septum). Similarly, RV end-diastolic and end-systolic volume indexes (ml/m2) were not significantly affected by coronary sinus cardioplegia, being 71.6 +/- 5.8 and 36.1 +/- 3.5 before, and 67.4 +/- 3.8 and 34.5 +/- 2.3 after aortic valve replacement, respectively. We conclude that retrograde coronary sinus cardioplegia does not cause a detectable impairment of RV function if the balloon catheter does not obstruct the terminal tributaries of the coronary sinus and, hence, does not impede delivery of cardioplegia to right-sided cardiac structures.

[Abnormalities of the aortic arch in adults. A rare cause of tracheo-oesophageal compression. Apropos of 2 cases]. / Les anomalies des arcs aortiques chez l'adulte. Une cause rare de compression trachéo-oesophagienne. A propos de deux cas.

Two cases of symptomatic aortic arch anomalies in adults are reported: a case of Neuhauser's ligamentum arteriosum with compressive retro-oesophageal diverticulum, and a case of double aortic arch revealed by postoperative tracheal compression. In both cases, surgical correction was made very difficult by the aneurysmal progression of the compressive vascular anomalies and resection of the thoracic aorta under cardiopulmonary by-pass was necessary. These therapeutic difficulties therefore highlight the differences between aortic arch anomalies in adults and those in infants which can be simply and effectively treated with no mortality in our experience. These observations argue in favour of systematic surgical correction of any aortic arch anomalies in infants, even when they are responsible for few symptoms.

[Surgical treatment of infectious endocarditis on a native valve. Apropos of 71 cases]. / Traitement chirurgical de l'endocardite infectieuse sur valve native. A propos de 71 cas.

The results of surgery in a series of 71 patients operated upon for infective endocarditis on a native valve are presented. The patients' mean age was 35 years; the initial focus of infection was usually located in the mouth and the most frequent pathogens were staphylococci and streptococci. The aortic valve was most frequently involved. Only 26 patients underwent surgery after 40 days of antibiotic therapy; 34 were operated upon in a semi-emergency and 11 in an acute emergency. Pre-operative systemic embolism was common (20 cases), notably in the brain (17 cases), and 11 patients remained with sequelae. There was good correlation between the anatomical lesions found at surgery and the data obtained from pre-operative echocardiography. The operation was performed on one valve in 40 cases, on two valves in 20 cases and on three valves in 11 cases. Bioprostheses were used more often than mechanical prostheses. Hospital mortality was nil in patient who underwent elective surgery; it was 14.7 p. 100 in those operated upon in a semi-emergency and 27.3 p. 100 in those operated upon in an acute emergency. Nine patients developed late complications, mostly within 6 months of the operation; in particular, prosthesis disinsertion occurred in 4 cases, and progression of a pre-existing left cardiac failure was observed in 2 cases. In their conclusions the authors emphasize the reliability of echocardiography and the need for an early operation in cases with haemodynamic disorders in order to avoid severe myocardial failure and, if possible, systemic embolism and its fearsome sequelae.