[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.

Cancer of the kidney invading the vena cava and heart. Results after 11 years of treatment.

Between October, 1973, and October, 1983, 18 patients with cancer of the kidney or adrenal gland that had invaded the vena cava, and in 11 cases had reached the heart, were operated on by seven surgical teams. The surgical excision in all patients was performed with extracorporeal circulation, circulatory arrest and deep hypothermia. No deaths occurred. If there are no detectable metastases before operation, the 5 year survival rate is 75% as compared to 6 months with medical treatment. This clinical situation is not uncommon, as 3% to 10% of cancers of the kidney invade the inferior vena cava and 40% of them reach the heart. The possibility of curing the cancers with minimal operative risk should prompt a systematic search for venous invasion with any cancer of the kidney.

Choledochoscopy in surgery for choledocholithiasis. Six year experience in 380 consecutive patients.

Choledochoscopy is a definite advance in biliary surgery as it simplifies the operative procedure and decreases the retained stone rate. Easy to perform without special training, its use is cost-effective. Therefore, we agree with Kappes et al [10] recommendation that routine intraoperative biliary endoscopy be performed in all patients undergoing common bile duct exploration.

Partial ileal bypass in type II familial hypercholesterolemia. Eleven-year experience at the Montreal Heart institute.

The National Heart, Lung, and Blood Institute is currently sponsoring a multicenter clinical trial to evaluate the long-term efficacy of partial ileal bypass in the prevention of recurrent myocardial infarction in hypercholesterolemia patients. Thus we felt that a report of our clinical results with this intervention at the Montreal Heart Institute during the last 11 years would be of interest. Twenty patients with type II hyperlipoproteinemia and a mean age of 38 (range 25-54) years underwent partial ileal bypass between March 1971 and April 1978. This intervention was associated with aortocoronary bypass surgery in 11 patients. All patients were followed at regular intervals. The mean survival time was 70.7 (range 1-123) months. Two deaths were observed during follow-up, one from an acute myocardial infarction and the other from ventricular fibrillation, respectively, 1 month and 1 and one-half years after partial ileal bypass. The ileal bypass was undone twice because of gastrointestinal problems including a malabsorption syndrome and repeated episodes of subocclusion. A progressive decrease of the effects of the operation on serum cholesterol was noted, from a 33 per cent reduction at 3 months to 43 per cent at 2 years and 16 per cent at 6 years. Two patients presented an acute myocardial infarction respectively 3 and 4 years after the operation, respectively, and one patient suffered a right-sided hemiplegia at age 30, 12 months after the operation. Of 14 patients with angina pectoris preoperatively (class III in 10), eight remained symptomatic postoperatively (class I and II angina in five).(ABSTRACT TRUNCATED AT 250 WORDS)

Choledochoscopy in common bile duct surgery for choledocholithiasis: A must: Eight years experience in 441 consecutive patients.

Between 1975 and 1983, 441 choledochoscopy were performed in a series of 451 consecutive patients undergoing surgical common biliary duct exploration for choledocholithiasis. In 127 patients (27.8%), no stones were found. Forty-five cases (10%) of choledocholithiasis missed by surgical and radiologic exploration methods were found by choledochoscopy. Therefore the retained stone rate decreased from 10 per cent to 2 per cent. Fourteen patients (3%) died at surgery, ten of whom (2%) were over 70. Postoperative biliary tract was drained in 98 patients (8%) using external drainage. Biliary tract patency was checked on the tenth postoperative day by the tube cholangiography. When retained stones were not found, T-tube was removed on the 20th day after surgery. When retained stones were found (11 patients, 2%) an endoscopic papillotomy was performed. Choledochoscopy is a significant addition in biliary surgery. It reduces operative mortality and morbidity, decreases retained stone rate, diminishes indications for biliary anastomosis and sphincterotomy, and is easy to perform without specific training. Its extensive and systematic use is advocated when- ever common bile duct patency has to be surgically demonstrated in choledocholithiasis.

Venous plethysmography applied in pathologic conditions.

The correlation between venography and SGP in 41 patients was studied. Fourteen normal subjects were used as a reference. SGP was shown to be very sensitive (97.5%), including proximal and distal DVT, and highly specific (96.4%). After some recommendations for patient positioning and technical use, it will enhance both the accuracy and the reproducibility of plethysmography for evaluation of patients with suspected deep venous thrombosis.

[Surgical revascularization of infarcted myocardial areas. Its effects on left ventricular function]. / La revascularisation chirurgicale des territoires myocardiques infarcis. Ses effets sur la fonction ventriculaire gauche.

The results of twelve patients undergoing revascularisation procedures of infarcted myocardial territory alone were analysed quantitatively by planimetry in the right anterior oblique projection. Patients operated in the acute phase of myocardial infarction (2 cases) were distinguished from those with preinfarction syndromes (8 patients) and those with postinfarction angina (2 patients). Two posterior wall and ten anterior wall revascularisations were carried out by single bypass grafts (8) and double bypass grafts (2) with no operative deaths. The results were assessed 2 months to two years after operation (average: 6 months). Twelve of the fourteen bypass grafts were patent. Only one of the twelve operated patients, an anterior wall revascularisation, was considered a complete surgical failure: global left ventricular function and segmental wall movement progressively deteriorated with reduced contractility and velocity of fibre shortening. Improved contraction of both anterior and posterior walls was observed in the other 11 patients. The ejection fraction of the 9 patients with anterior wall revascularisation rose significantly from 47,1 +/- 10,5% to 56,3 +/- 3,5% and a similar rise was observed in systolic index (29,0 +/- 12,0 to 36,8 +/- 11,0 ml/syst./m2); the average akinetic end diastolic perimeter fell by 17%; segmental wall analysis of mean radial shortening and mean amplitude of excursion on the hemiaxes was improved, especially in the antero apical region: the corrected rates of mean excursion and average systolic work indices (33,2 +/- 15 to 41 +/- 13 gm/syst./m2) also increased. Surgical revascularisation of infarcted zones, made possible by new methods of cardioplagia and reliable circulatory assistance, may lead to improvement in global and segmental left ventricular function with minimal risk to the patient: this is thought to be due to an active mechanism and not to the passive process of scarring. Although a reserved attitude should be adopted in the acute phase of myocardial infarction, preinfarction syndromes and unstable postinfarction angina could well benefit from surgical management.

[Experimental model for hemodynamic and metabolic studies of extracorporeal circulation. Apropos of 14 cases]. / Modèle expérimental pour l'étude hémodynamique et métabolique de la circulation extra-corporelle. A propos de 14 cas.

The authors present an homogeneous and stable experimental model, the basic characteristics of which are: 14 extracorporeal bypass with: total bypass; normothermia; total haemodilution; beating heart; continuous flow in dogs anesthetised with chloralose. Three methods were employed: continuous recording of the venous lactate concentration; invasive electromagnetic measurement of the arterial blood flow; measurement of the tissular capillary blood flow with radioactive labelled microspheres. The statistic treatment of the informations gathered confirms that those experimentations took place in normothermia and constant: pH, venous and arterial pressure, cardiac pacing and arterial carotid blood flow. We noticed no modification of the body electrolytic repartition; blood gas variations do not modify haemodynamic conditions. Increase of the lactate concentration, as noticed in the literature, is in relation with a catecholamine hypersecretion and not with an anaerobic tissular function. Tissular capillary blood flow is constant if reported to cardiac index. This model will allow us to compare those results with new series where only one of the basic elements will be modified.

[Role of thrombolytic treatment in thrombosis of valvular prostheses. Apropos of 2 cases and review of the world literature]. / Place du traitement thrombolytique dans les thromboses des prothèses valvulaires. A propos de 2 cas et revue de la littérature mondiale.

The authors report 2 cases of thrombolytic therapy by Urokinase at the dose of 4 500 U/kg/hour, for 24 hours, in patients with thrombosis of a Bjork aortic and Lillehei mitral valve prostheses, and assess the efficacy with a review of the world literature. The first case was a 65 year old woman who received a Bjork No 25 aortic valve prosthesis for aortic regurgitation. Two years later oral anti-vitamin K anticoagulants were replaced by an association of Aspirin-Persantine. She developed acute pulmonary oedema secondary to thrombosis of her valve during the fifth postoperative year. Treatment with Urokinase was successful (4 500 U/kg/hour for 24 hours). The second cases was a 33 year old woman who received a Lillehei No 27 mitral valve prosthesis for mitral regurgitation due to infective endocarditis. Six years later, during a period of apparently ineffective oral anticoagulation, she developed subacute pulmonary oedema due to thrombosis of her prosthesis. Urokinase therapy was successful after 4 hours, but the valve surface area on cardiac catheterisation was decreased and elective reoperation to change the prosthesis was decided upon. Prosthetic valve thrombosis is a serious complication with an operative mortality of 68.6% (35 deaths out of 51 reoperations in the worl literature) whilst the efficacy of thrombolytic therapy would appear to be about 80%. When thrombosis is progressive, the valve has to be changed surgically, but when it is secondary, thrombolytic therapy at least helps the patient survive the acute phase.

[Technical modification of transaxillary resection of the first rib in surgery of thoraco-brachial outlet syndromes]. / Modification technique de la résection de la première côte par voie transaxillaire dans la chirurgie des syndromes de la traversée thoraco-brachiale.

From April 1985 to September 1991, 88 patients were operated for a total of 100 thoracobrachial outlet syndromes. The patients were placed in the dorsal supine position, turned 30 degrees towards the contralateral side. The arm was suspended in slight abduction. The access obtained is identical to that obtained with the classical operation. No direct traction or compression is exerted on the pedicles during retraction and the operation requires a single assistant. The composition, indications and results of our series are similar to those reported in the recent literature. We did not observed any immediate or late neurological complications. We conclude that thoracobrachial outlet syndromes can be treated via an axillary approach using mechanical traction and a single assistant without increasing the risk of neurological complications.

[Migration of an Antheor filter in the pulmonary artery. A case]. / Migration d'un filtre Anthéor dans l'artère pulmonaire. Une observation.

Migration of an Antheor caval filter into the pulmonary artery was observed in a 66-year old male patient referred for multifocal pulmonary embolism in a context of heparin-induced thrombocytopenia. The inferior vena cava was of small diameter (18 mm). The filter was removed under cardio-pulmonary bypass and total heparinization, despite the proven thrombocytopenia. The postoperative period was marked by tamponade which had to be drained. The long-term results were satisfactory. This seems to be the first documented case of Antheor caval filter migration into the cardiac cavities.

[Prospective study of the long-term permeability of the internal saphenous vein and of polytetrafluoroethylene in the lower femoro-popliteal bypass. Results after 5 years in 100 patients]. / Etude prospective de la perméabilité à long terme de la veine saphène interne et du polytétrafluoroéthylène dans les pontages de sauvetage fémoro-poplité bas. Résultats à cinq ans chez 100 malades.

Autogenous saphenous vein (ASV) (50 patients-group I) was compared to polytetrafluoroethylene (PTFE) (50 patients group II), in 100 below-knee femoropopliteal bypass (FPB) procedures performed for limb salvage during à 5 year-period. PTFE was used as an alternative procedure in the absence of a suitable ASV. Each group made of 50 patients was not significantly different from the other. The mean follow up period for patent graft is now 35 months (12-60 months) and the overall life table cumulative patency at 5 years, is 65% in group I and 18% in group II (P less than 0.05) whereas the limb salvage rate (LSR) is 81% with ASV and 26% PTFE (P less than 0.05). No correlation was demonstrated between patency and run-off. The graft described was used in elderly patients most of whom would have had amputation before the introduction of PTFE. Theses results advocate the use of PTFE only in secondary intention and never to shorter operation time.

[Aorto-iliocaval fistula caused by rupture of an aneurysm. Apropos of 3 cases]. / Fistule aorto et ilio-cave par rupture d'anévrysme. A propos de trois cas.

Three cases of aorto-iliocaval fistula are reported. Two cases were diagnosed during operation, an emergency laparotomy being indicated by the picture of hemodynamic shock unimproved by intravenous fluids, and without reduction in number of circulating red cells, associated with a painful abdominal aorta aneurysm. Recovery occurred after surgical closure of fistula and grafting of the aneurysm. In one case a caval stenosis required the insertion of a prophylactic subrenal clip. The third case was original in that a paradoxical pulmonary embolus developed in a patient with a primary left iliac aneurysm complicated by phlebitis. The hemodynamic state was such that a first stage operation. allowed insertion of a Greenfield's filter by the jugular route. Arteriography confirmed the diagnosis of a fistula and surgery was successful. Possible clinical manifestations of aortocaval fistula and surgical therapeutic measures are discussed.

[Early return to work after arterial surgery and strict control of disabled patients]. / Reprise précoce du travail après chirurgie artérielle et contrôle strict des invalides.

Coronary surgery represents an increasing economic burden to society. This is aggravated a great deal by the fact that these patients do not return to work and are often placed in permanent postoperative disability. Comparative analysis of return-to-work rates after coronary by-pass, according to the social benefits system, clearly demonstrates the magnitude of the possible savings. Attending physicians, specialists and experts must, therefore, motivate the patients with total disability.

Clinical results of the aortic Medtronic-Hall prosthesis.

Between July 1979 and June 1982 we implanted aortic Medtronic-Hall prostheses in 40 patients. Ages ranged between 25 and 75, with a mean of 56 years. There were 38 cases of elective surgery (group I) and 2 acute aortic dissections (group II). All patients received anticoagulant medication. Follow-up ranged between 8 and 39 months with a mean of 22.5 months. Excluding operative mortality (7.5%) the 2-year actuarial survival rate is 97.2%. No death was related to the valve or its dysfunction. The overall thromboembolic rate is 0.78 per 100 patient years. No thromboembolic episode occurred in group I. No hemolysis was encountered and most patients experienced marked postoperative improvement. We consider that aortic Medtronic-Hall valves are valuable but further studies are necessary to confirm the results we obtained.