[Long-term development of aortic valve stenosis surgically treated at an advanced stage]. / Evolution à long-terme des rétrécissements aortiques opérés à un stade évolué.

From January 1972 to June 1990, 112 patients (39 to 83 years old), 67 males and 45 females were submitted to surgery for sever calcified aortic stenosis. 68 patients were in NYHA III (60.72%) and 44 in NYHA IV. Early mortality included 8 patients (7.14%), 6 died for cardiac reasons. Late mortality was 27.67%. Actuarial survival rate (including postoperative mortality) was 88.39%, 77.67%, 67.85% and 65.17% at one year, five, ten and fifteen years, respectively. Results were significantly correlated to left branch block on preoperative EKG, episodes of complete heart failure, significant coronary stenosis, the cardioplegia technique and the association with coronary bypass.

[Hemodynamic effects of propofol]. / Effets hémodynamiques du propofol.

The new form of propofol gives the same haemodynamic effects as the old one (propofol diluted in cremophor EL). There are few experimental studies concerning the haemodynamic effects of propofol. In the dwarf pig, Glen and Turner found a fall in arterial blood pressure and peripheral resistances, whilst the heart rate and cardiac output rose. In man, studies have shown that propofol gives haemodynamic effects similar to the other intravenous anaesthetic drugs, and especially thiopentone. In subjects with a healthy heart, and for doses included between 1.5 and 2.5 mg X kg-1, propofol gave a 25 to 30% fall in arterial blood pressure. There are also a 20% fall in peripheral resistances and a small fall (10%) in cardiac output. Blood pressure returned to its initial level 3 to 5 min after the injection. The heart rate was not much changed, and rather slowed, perhaps because of central vagotonia. When propofol was used to maintain anaesthesia, either by repeat injections, or by infusion, with the patient breathing spontaneously and not undergoing painful stimuli, blood pressure and heart rate remained steady within 55 to 65% of their initial values. Propofol appeared to avoid to some extent the increase in blood pressure and heart rate seen during intubation. When propofol and fentanyl were used together, the cardiovascular effects were more pronounced than when they were used alone. Moreover, propofol appeared to limit to a large extent the hypertension due to intubation and sternotomy in patients undergoing aorto-coronary arterial graft surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dopexamine: a new catecholamine used in the treatment of low cardiac output after heart surgery]. / Dopexamine: nouvelle catécholamine utilisable dans le traitement des syndromes de bas débit après chirurgie cardiaque.

The value of dopexamine hydrochloride, a beta 2 agonist with dopamine-like and weak beta 1 effects, for the treatment of low cardiac output was investigated in twelve patients. All had undergone cardiac surgery (valve replacement, aorto-coronary bypass), and had a cardiac index (C1) less than 21.min-1.m-2, low urine output (17 +/- 23 ml.h-1), and poor peripheral perfusion (peripheral cyanosis, cold hands and feet). Systolic arterial blood pressure was decreased, but over 80 mmHg. Diastolic pulmonary arterial or wedge blood pressure was more than 15 mmHg. Usual haemodynamic monitoring was carried out using arterial and Swan-Ganz catheters. Dopexamine hydrochloride doses were increased every 15 min by increments of 1 microgram.kg-1.min-1, up to a maximum dose of 8 micrograms.kg-1.min-1, so as to determine the optimal dose for each patient. This dose was then given for a period of up to 48 h. During the initial titration phase, heart rate increased by 37% from control at a dose of 4 micrograms.kg-1.min-1, this increase becoming less important at higher doses (13% at 8 micrograms.kg-1.min-1). Mean arterial blood pressure increased by 13% at a dose of 2 micrograms.kg-1.min-1. Mean pulmonary arterial blood pressure did not change significantly, but wedge pressure fell by 25% at 4 micrograms.kg-1.min-1. Simultaneously, CI increased by 56%, and systemic vascular resistances decreased by 31% (p less than 0.005). During the continuous steady rate infusion period, heart rate fell to a level of about 100 b.min-1.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of propofol in anesthesia in cardiac surgery. Preliminary results]. / Utilisation du propofol pour l'anesthésie en chirurgie cardiaque. Résultats préliminaires.

Nine patients, all NYHA class III and IV, who were to undergo surgery with cardiopulmonary bypass, were divided into two groups. All nine were premedicated with 2 mg flunitrazepam orally 90 min before surgery. Group A consisted in five men, mean age 53 years (extremes: 43 and 73), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (2), mitral valve replacement (2), and aortic and mitral valve replacement (1). They were given 1.5 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 50 micrograms X kg-1 X min-1 propofol. Group B consisted in four patients, two men and two women, mean age 60 years (extremes: 49 and 76), with no significant difference in weight and body surface area, who were to undergo aortic valve replacement (3) and corrective surgery for left ventricular aneurysm (1). They were given 2 mg X kg-1 propofol as a bolus at induction, followed by an infusion of 100 micrograms X kg-1 X min-1 propofol. All the patients were intubated after 0.1 mg X kg-1 pancuronium; they were given 10 micrograms X kg-1 before intubation and 10 micrograms X kg-1 before skin incision. Repeat doses of fentanyl and pancuronium were given as required. The haemodynamic parameters studied were: heart rate, systolic, diastolic and mean blood pressures, central venous pressure, mean pulmonary pressure, wedge pressure, and cardiac output measured by thermodilution. The following indices were calculated: cardiac index, systolic index, right and left systolic work indices, and pulmonary and systemic vascular resistances.(ABSTRACT TRUNCATED AT 250 WORDS)

[Plasma concentrations of diltiazem and its metabolites in coronary surgery: relation with preoperative treatment]. / Concentrations plasmatiques du diltiazem et de ses métabolites en chirugie coronarienne: relation avec le traitement préopératoire.

Preoperative oral administration of calcium channel blocking agents has been found ineffective to prevent perioperative myocardial ischaemia. Our hypothesis was that low plasma concentrations may account for this inefficiency. Twenty-three male patients, scheduled for surgical myocardial revascularisation, were administered their usual anti-anginal treatment, including 180 to 360 mg of diltiazem since more than one week. The usual dosage was given at 8.00 p.m. on the day before surgery. On the morning of surgery, after withdrawal of a first blood sample, 60 mg of diltiazem were administered per month before the induction of anaesthesia. The anaesthesia was obtained with fentanyl, midazolam or flunitrazepam, pancuronium and isoflurane as required. The cardiopulmonary bypass (CPB) was associated with total haemodilution with Ringer's Lactate and a membrane oxygenator. A second blood sample was withdrawn after CPB. Plasma concentrations of diltiazem and its two active metabolites, N-monodemethyldiltiazem (MA) and desacetyldiltiazem (M1), were assessed by HPLC. Plasma diltiazem concentrations decreased from 78 +/- 66 (mean +/- SD) to 51 +/- 42 micrograms.l-1 (p < 0.05) with wide individual variations. These concentrations were under therapeutic levels in 18 out of 23 patients before (p < 0.05) with wide individual variations. These concentrations were under therapeutic levels in 18 out of 23 patients before induction and in 22 patients after CPB. The metabolite/diltiazem ratios remained constant. A dosage-plasma concentration relationship was observed preoperatively with diltiazem and MA. It is concluded that plasma concentrations of diltiazem should be optimized preoperatively in order to prevent myocardial ischaemia.

[Modification of a continuous positive airway pressure in view of its use in postoperative resuscitation in cardiovascular and thoracic surgery]. / Modification du circuit de CPAP "P.P" en vue de son utilisation en réanimation postopératoire de chirurgie cardiovasculaire et thoracique.

This paper describes a modification of a CPAP "P.P" circuit. This modified circuit is used to wean from artificial ventilation: 1) Patients exhibiting an hypoxia when undergoing a T piece trial with high FiO2. 2) Patients presenting pulmonary pathology before the operation. 3) Patients with cardiogenic shock so long as controlled mandatory ventilation is not an absolute requirement. This modification of a CPAP "P.P" circuit may have general use in the post-operative care after cardiovascular and thoracic surgery.

[Treatment of low cardiac output following extracorporeal circulation with captopril]. / Traitement du bas débit cardiaque post-CEC par le captopril.

Seven patients in low-output cardiac failure, resistant to conventional vasodilators and inotropic agents, following surgery with extra-corporeal circulation were given oral captopril, an angiotensin converting enzyme inhibitor. The effects of captopril on haemodynamic and renal function were studied after 2, 6, 12 and 24 hours of treatment. After two hours, there was a mean reduction in systemic arterial resistance of 29%, in pulmonary arterial resistance of 18% and in pulmonary wedge pressure of 15%. The mean increase in the cardiac index was 28%. This marked initial haemodynamic improvement was either maintained or increased over the rest of the 24 hours. By 24 hours there had been a mean increase in urinary sodium excretion of 200%. The urinary sodium/potassium ratio increased from 0.62 to 1.45. Oral captopril thus seems suitable for treating low-output cardiac failure following surgery requiring extra-corporeal circulation.