Use of von Willebrand diseased kidney as donor in a pig-to-primate model of xenotransplantation.

BACKGROUND: The coagulation process in hyperacute and delayed xenograft rejection is essential and depends upon platelet adhesion and aggregation. The initial binding of platelets to the damaged endothelium is due to the interaction of the platelet receptor glycoprotein Ib with von Willebrand factor (vWF), which is present on activated endothelial cells and bound to the subendothelial matrix. We hypothesized that the use of organs from animals with homozygous von Willebrand disease (vWD), severely deficient in vWF, might prevent the thrombosis encountered in delayed xenograft rejection. METHODS: Ten baboons were treated by extracorporeal immunoadsorption of xenoreactive natural antibodies (XNA) through the donor pig liver to inhibit hyperacute rejection and received heterotopic vWD or control pig kidney xenografts. XNA levels, coagulation, and platelet activation markers were studied, and specimens of rejected kidneys were analyzed histologically. RESULTS: Although XNA depletion was comparable in both groups, neither kidney function nor survival times of control (n=5) or vWD (n=5) porcine kidneys showed any difference. Platelet and coagulation activation was evidenced in both groups after surgery and at rejection time. Immunohistochemical analysis revealed a weak endothelial vWF immunostaining in the rejected vWD kidneys, whereas it was undetectable in the nongrafted vWD kidneys, suggesting the deposition of baboon plasma vWF on the porcine vessels. CONCLUSIONS: The use of vWD organs did not improve the survival time of grafted kidneys in this xenotransplantation model. Further studies on the use of vWD organs, in association with other therapeutic approaches, such as complement inhibition, are nevertheless necessary to evaluate the usefulness of vWF deficiency as an adjunctive therapy to decrease the coagulation process during xenograft rejection.

Anatomic, clinical, and therapeutic features of acute cardiac rupture. Successful surgical management fourteen hours after myocardial infarction.

A 62-year-old man sustained an acute myocardial infarction complicated on the thirteen hour by left ventricular rupture and acute periocardial tamponade. Echocardiography confirmed the suspicion of intrapericardial fluid, and immediate pericardiocentesis improved the hemodynamic state for a period sufficient to permit preparation for operation. Resection of ruptured and necrotic anteroapical left ventricular myocardium with primary reconstruction was successfully accomplished with the aid of temporary extracorporeal circulation. The patient has remained well for 1 year after the operation. Anatomic, clinical, and therapeutic features of acute cardiac rupture are discussed.

Removal of primate xenoreactive natural antibodies by extracorporeal perfusion of pig kidneys and livers.

Organ perfusion is one of the possible strategies to attenuate rejection of discordant xenografts by reducing the levels of the recipient's xenoreactive natural antibodies (XNA). Its efficacy in terms of XNA removal was studied in models of primate blood or plasma perfusion through porcine kidneys or livers, with special attention to haematological consequences and potential side-effects. We first perfused the blood of rhesus monkeys through pig kidneys and livers, and demonstrated that the perfusion of a pig liver resulted in higher XNA adsorption (72 +/- 13%) than the perfusion of a pig kidney (51 +/- 25%). However, when we normalized for the weight of the perfused organs and for levels of natural antibodies in individual monkeys, livers adsorbed less antibody (1.4 +/- 0.9 U antibody/g) than kidneys (7.2 +/- 7 U antibody/g). Histological signs of rejection were observed in perfused kidneys, but not in perfused livers. A major drawback of the perfusion of blood through livers was a considerable decrease in the primates' haemoglobin and platelet levels. To avoid this, we developed a plasma liver perfusion device. This method allowed a significant improvement in the haemodynamic state of primates and was particularly effective in preventing anaemia. Moreover, plasma liver perfusion was as effective as blood liver perfusion to remove natural antibodies and, resulted in a marked decrease in their functional activity as assessed by complement-dependent cytotoxicity (CDC) and antibody-dependent cell-mediated cytotoxicity (ADCC). The level of other plasma proteins was not significantly affected, apart from a dilution effect. After xenoperfusion a strong antibody response was evidenced by ELISA, CDC and ADCC between days 7 and 14 and then decreased progressively. We conclude that the separation of blood to allow the perfusion of plasma through a pig organ is safer than the perfusion of unseparated blood and is associated with efficient natural antibody removal. However, organ perfusion is limited by a rebound in antibody levels after a few days, and thus will have to be associated with anti-B cell immunosuppressive therapy for long-term or repeated applications.

Intrapericardial teratoma in a newborn infant: use of fetal echocardiography.

The case of an infant with intrapericardial benign teratoma, which was suspected in utero after fetal echocardiography, is reported. This new approach permitted very early diagnosis and surgical treatment before cardipulmonary distress appeared. The tumor was excised completely, and the patient was asymptomatic three months postoperatively.

Traumatic lesions of the thoracic aorta. A report of 73 cases.

In a 24 year period we treated 73 traumatic lesions of the thoracic aorta; 36 of these were acute ruptures and 37 post traumatic pseudo-aneurysms. All these cases were associated with violent, sudden deceleration and in 68 instances the cause of this was a traffic accident. Fifty two patients (70%) had severe associated lesions involving the cranium, abdomen, thorax or leg fractures and dislocations but in 5 patients the aortic rupture was the only injury observed. Thirty four patients with acute aortic lesions were operated upon; 30 with extracorporeal circulatory assistance (CA) and 4 with aortic cross clamping alone. Twenty one were repaired by direct suture, 13 by prosthetic graft interposition and there were 8 deaths (23.5%) and one case of post-operative paraplegia. Thirty six traumatic aneurysms were operated upon; 34 with CA and 2 with cross clamping. Only two were repaired by direct suture, 5 by prosthetic angioplasty and 29 required prosthetic interposition grafts; there were no deaths or paraplegias in this group. Aortic rupture demands early diagnosis and immediate surgery. Associated abdominal injuries are easily missed and therefore exploratory laparotomy should be considered after every acute aortic repair.

What is the place of pulmonary embolectomy today?

From 1.1970 to 31.12.1989, 134 patients with pulmonary embolism were treated by pulmonary embolectomy (74 women and 60 men) of mean age 55 years (23-78 years); 93 (69%) of these patients developed embolism during the postoperative period following surgery for another condition. In 12 cases the embolectomy was performed without circulatory assistance by a modified Trendelenburg operation after an average delay time of 2 hours. In 122 cases, extracorporeal circulation (ECC) was used, preceded in 64 cases, by a femoral-femoral bypass (the average delay interval of operation being 16.9 hours). At operation, 23 patients were in complete circulatory failure needing external cardiac massage, 34 were in cardiogenic shock with systolic arterial pressures (SAP) less than 60 mmHg, 42 maintained their arterial pressure between 60 and 100 mmHg, and only 35 were seen with SAP higher than 100 mmHg under vasopressive drugs. No haemodynamic and angiographic investigations could be undertaken in 31 patients because of their dramatic clinical state. In the other 103 patients who had invasive angiographic investigations performed the pulmonary bed was obstructed from 65% to 90% (mean 79.4%) according to Miller's index. The mean arterial pulmonary pressure was 51.2 mmHg. The survival rate at the 30th postoperative day showed 113 patients were alive (84.3%) with 7 among the 12 operated by the Trendelenburg's modified method and 106 among the 122 operated under ECC. The main causes of the 21 deaths were: peroperative 8, neurological 4, cardiac 4, respiratory 1, recurrent embolism 1, acute thrombosis of the IVC 1. Our results of pulmonary embolectomy can be compared favorably to those obtained by thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial emboli of the upper extremity: a persisting problem.

From 1969 to 1980, 154 emboli of the upper extremities (UEE) were managed in our institution. They occurred in 151 patients, 66 males (44%) and 85 females (56%) aged ranged from 23 to 87 years (mean 68.9). Obstruction level was in the subclavian artery (12 cases), the axillary artery (46), the brachial artery (74 cases), the radial or ulnar artery (22 cases). Cardiac disease was present in 119 cases. Ischemia was severe in 47 cases (30%), and partial in 104 (67%). Peripheral gangrene was already present in 2 cases. 106 patients were operated on within 10 hours after the occurrence of UEE (69%). Associated systemic emboli was noted in 10 cases. The treatment consisted in 140 primary embolectomies and in 11 cases of conservative therapy (heparin 10, thrombolysis 1). Reoperation was done in 11 patients (7%) because of recurrence of UEE and in 4 cases (2%) for post-operative thrombosis. Results were good in 128 patients with clinical improvement and arterial patency.

Acute post-infarction left ventricle rupture. Five operations with three long-term survivals.

Cardiac rupture is cause of death in myocardial infarction. Surprisingly only seventeen successful attempts at operative treatment have been published, with a rather good long term survival. The authors report five cases of cardiac rupture operated upon with two deaths and three long term survivals. Frequency, clinical features and surgical possibilities are discussed with particular insistance on a rather aggressive surgical attitude when considering this complication.

[Right juxtaposition of the atria. Apropos of one case without associated trunco-conal abnormalities]. / Juxtaposition droite des auricules. A propos d'une observation sans anomalie tronco-conale associée

A child of 7 had coarctation of the aorta and an atrial septal defect. In the course of surgery to close the septal defect, she was found to have a right-sided juxtaposition of the appendages. This is a very rare abnormality, with no symptoms of its own, but usually associated with severe cardiac malformations especially of the truncus and conus. This case report is most unusual because of the right-sided disposition of the appendages and the absence of any serious associated cardiac lesion.

[Transesophageal echography and peripheral arterial embolism. A new etiologic approach. Apropos of 87 cases]. / Echographie transoesophagienne et embolies artérielles périphériques. Nouvelle approche étiologique. A propos de 87 cas.

This prospective study (September 1989 to November 1990) was undertaken to evaluate the utility of transesophageal echocardiography in acute peripheral ischaemic syndromes. After embolectomy or thrombolysis, 87 patients with an average age of 69.7 years underwent not only the usual investigations (conventional echocardiography, abdominal ultrasonography and Holter monitoring) but also transesophageal echocardiography within 2 days of the ischaemic events (lower limb 84%, multiple embolism 11%, recurrent embolism 13%). Atrial fibrillation was documented in 44 patients (50.5%), 19 patients had chronic arterial disease (22%), 8 patients had valvular heart disease (9%) and 2 patients had a blood disorder (2%). Transthoracic echocardiography only demonstrated one left ventricular apical thrombus whereas transesophageal echocardiography showed residual thrombus in 22 patients (25%) mainly in the left auricle but also in the descending thoracic aorta (8 patients) as a mobile, pediculated thrombus or lining an aortic aneurysm, thereby opening up new therapeutic possibilities. In addition, double aortic dissection was diagnosed in a patient who was not echogenic, isolated spontaneous contrast in 20 patients (23%) and other abnormalities in 7 patients (8%). Statistical analysis showed a significant relationship between the presence of thrombus and/or spontaneous contrast in the left atrium and/or left auricle and the size of the left atrium (Fisher test - p = 0.0073), and the presence of a supraventricular arrhythmia (chi 2 test).

[Ductus arteriosus in neonatal cyanotic cardiopathies. Value of the recording of the cutaneous partial pressure of oxygen]. / Le canal artériel dans les cardiopathies cyanogènes néonatales. Intérêt de l'enregistrement de la pression partielle cutanée en oxygène.

Adaptation to extrauterine life is always precarious in the newborn with cyanotic cardiac malformations. Limited survival is possible in cases with obstructive lesions of the right heart providing ductal closure is delayed. This was monitored in 3 cyanotic neonates with ductal dependant cardiac malformations (tricuspid atresia, transposition of the great arteries with atresia or severe stenosis of the pulmonary valve) by continuous measurement of the cutaneous pO2. The value of cutaneous pO2 monitoring has already been established. It is a reliable indicator of arterial pO2 in the neonatal period. Its major advantage, apart from the possibility of continuous monitoring, is that it is non-invasive and may be performed at the bedside. Analysis of curves recorded over several hours or days showed the cyclical nature of cutaneous pO2, probably related to slow variations in ductal diameter equilibrating effective pulmonary flow, arterial pO2 and ductal constriction. Prolonged hyperoxygenation of these desaturated children does not usually improve their condition; progressive deterioration due to the constrictive effect of oxygen on the ductus may be observed. When a clear decrease in the amplitude of oscillation is recorded ductal closure is imminent and palliative surgery should be undertaken whenever possible.

[Long-term course of syphilitic aortic insufficiency with ostial stenosis following surgical treatment]. / Evolution à long terme, après traitement chirurgical, des insuffisances aortiques avec sténoses ostiales d'origine syphilitique.

Syphilitic aortic insufficiency and coronary ostial stenosis is a rare condition. It was diagnosed in 8 patients referred for surgery. The infection, acknowledged in 3 cases, was contracted over 15 years prior to admission! The operative indication was aortic valve replacement in 6 cases (Stage II to IV dyspnoea) and coronary insufficiency in 2 cases (Stage III angina pectoris). Two cases of ostial stenosis were not identified at coronary angiography, illustrating the potential diagnostic pitfall of a disease which is often unrecognised nowadays. Preoperative echocardiography of the left main coronary artery, especially its intra-aortic segment, may be of value but was not performed in these old cases. Surgery consisted in aortic valve replacement and coronary revascularisation by decortication of the ostia or coronary bypass (1 case). The evolution was excellent in the 6 survivors, especially with respect to the anginal syndrome which was completely cured without associated treatment. A protocol of echocardiographic surveillance of the left main coronary artery has been instituted in these patients to detect any late postoperative changes after ostial decortication.

[Early surgical treatment of a septal perforation complicating a posterior infarct. Value of the diaphragmatic left ventricular approach]. / Cure chirurgicale précoce d'une perforation septale compliquant un infarctus postérieur. Intérêt de l'abord ventriculaire gauche diaphragmatique.

The authors report the case of a 53 year old patient who required operation on the 5th day after postero-inferior myocardical infarction for a poorly tolerated perforation of the ventricular septum. In discussing this case, they recall that the results for surgical repair of septal perforations complicating myocardial infarction are poorer when the infarction is posterior than when it is anterior. They suggest that this difference in prognosis is in large part due to the customary use in postero-inferior infarcts, of the right transventricular approach, which does not allow the infarct to be resected at the same time as the septum is closed. They finish by recommending the systematic use of a diaphragmatic approach to the left ventricle, including resection of the infarct, for all cases of septal perforations with posterior infarction in which surgery is necessary.

[Leiomyosarcoma of the left side of the heart with a mitral symptomatology. Echocardiographic study]. / Léiomyosarcome du coeur gauche à symptomatologie mitrale. Etude échocardiographique

A patient presented with the clinical findings of mitral stenosis, and angiocardiography revealed an intracardiac tumour. It was found at surgery to be a leiomyosarcoma, occupying almost the whole of the left auricle, and infiltrating the inter-atrial septum, the atrio-ventricular ring at the posterior commissure, and the posterior surface of the left ventricle. A mass with three lobes and a pedicle attaching it to the posterior wall and the ring of the mitral valve was found within the cavity of the left ventricle. The findings on echocardiography corresponded with the anatomical findings; but after surgery, ultrasonic investigation was found to be unreliable at detecting the unresected portion of the tumour, which was situated in the right postero-inferior region of the auricle of the left atrium.

[Post-traumatic interventricular communication. Closure under extracorporeal circulation].

Report of one case of acquired traumatic interventricular septal defect due to a stab injury of the right ventricle by a knife. The highly-placed penetrating injury involved the muscular septum and very probably resulted in a right bundle-branch block of the His system. Surgical operation performed in view of a starting clinical intolerance with moderately increased right cardiac pressures, was done under ECC with easy suture of the septal wound. The post-operative course was normal and a quick clinical cure was noted, which persisted for 8 months after surgery. The interest of this case, in addition to the very severe condition of the patient who had sustained 11 stab-knife wounds, lies in the high localization of the septal wound, which explains the involvement of the intracardiac conduction pathways.

[Massive mitral insufficiency due to spontaneous and isolated rupture of a posterior papillary muscle. Echocardiographic study, treatment by assisted circulation and prosthetic valve replacement]. / Insuffisance mitrale massive par rupture spontanée et isolée d'un muscle papillaire postérieur. Etude échocardiographique, traitement par assistance circulatoire et remplacement valvulaire prothétique.

The authors report a case of a patient of 72 years of age in whom the sudden onset of severe left ventricular failure led to the discovery of massive mitral incompetence. The diagnosis of rupture of the posterior papillary muscle of the mitral valve, which was suggested on clinical and echocardiographic grounds, was confirmed at operation. This was carried out after 72 hours of assisted circulation by counter-pressure, and consisted of a replacement by a prosthetic valve. The authors emphasise, in the light of this case, the importance of echocardiography by ultrasound in the early diagnosis of this type of acute mitral incompetence, clarify the signs, and emphasise the part played by assisted circulation with an intra-aortic balloon in the treatment of this condition.

[Massive pulmonary embolism Apropos of 26 embolectomies with definitive survival, 10 of them by Trendelenburg's operation]. / L'embolie pulmonaire massive. A propos de 26 embolectomies avec survie définitive, dont 10 par opération de Trendelenburg.

The authors report 26 pulmonary embolectomies carried out successfully, 10 of them having been Trendelenberg procedures and 16 having been carried out under extracorporeal circulation. The latter method gives better results, and appears to be the procedure of choice. The haemodynamics before operation were always abnormal, and there were 4 cardiac arrests, 11 cases of severe shock, and 6 cases with less severe hypotension. In the other cases, cyanosis, respiratory distress and signs of acute cor pulmonale were the clinical features of the massive embolus. It was possible to carry out arteriography in 14 cases, and this showed extensive pulmonary vascular obstruction in between 70 and 90%. In 4 cases this procedure was followed by an exacerbation, and extremely urgent treatment became neccessary. This examination is important for diagnosis and for assessment of the prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe prognosis. It seems clear to the authors that surgery has a certain place, alongside medical fibrinolysis of a severe pulmonary embolus. The essential indications for surgery are moribund patients, those in whom fibrinolysis is contraindicated or unsuccessful, and those with massive obstruction of the pulmonary arterial tree.

[Measurement of right systolic time intervals in complete transposition of the great vessels. Value in the surveillance of ventricular function]. / Mesure des intervalles de temps systoliques droits dans la transposition complète des gros vaisseaux. Intérêt dans la surveillance de la fonction ventriculaire.

Right ventricular function was regularly assessed pre- and postoperatively by measuring right systolic time intervals at the aortic valve in 21 children with complete transposition of the great arteries. Twenty children underwent "physiological" surgical correction (Senning procedure) and one child with right ventricular hypokinesia underwent detransposition of the arteries. The mean value of the right ventricular pre ejection/ejection period ratio was 0.40 +/- 0.05; this was independent of age and no significant difference was observed between the pre- and postoperative periods (0.41 +/- 0.06 vs 0.39 +/- 0.04) at least with a maximum follow-up of 5 years. This index allows early diagnosis of right ventricular dysfunction and therefore helps to orientate the choice between "physiological" or "anatomical" surgical correction.

[Aortic and mitral monovalvular replacements. Comparison of the ball prosthesis of Starr-Edwards (1260-6120) and the tilting disc prosthesis of Bjork-Shiley. Series of 390 patients]. / Remplacements monovalvulaires aortiques et mitraux. Comparaison des prothèses à bille de Starr-Edwards (1260-6120) et à disque basculant de Björk-Shiley. Une série de 390 patients.

The evaluation of short and long term replacement by the Björk-Shiley tilting disc prosthesis (BS) and by the Starr-Edwards ball and cage prosthesis (SE) was carried out on a series of 390 consecutive patients. In mitral replacement, operative mortality rate (SE 5.9 P. 100 - BS 4.8 P. 100), 5 year actuarial survival (SE 79.8 P. 100 +/- 3.8 P. 100 - BS 86.3 P. 100 +/- 9 p. 100) incidence of thromboembolic complications and valvular thrombosis (SE 1.6 P. 100 - BS 1.3 P. 100) as well as the degree of post-operative improvement were virtually identical in both types of prosthesis. Likewise, in aortic valve replacement, operative mortality rate (SE 4 p. 100 - BS 3.2 p. 100), 5 year survival (SE 82 +/- 7.8 P. 100 - BS 86 +/- 3.3 p. 100) incidence of thromboembolic complications (SE 2.2 p. 100 - BS 1.8 p. 100) and the degree of post-operative improvement were not statistically different. However, the incidence of sudden death was statistically smaller with a BS prosthesis than with a SE prosthesis (respectively 1.6 p. 100 and 6.9 p. 100).

[A treatable condition: parietal rupture of the heart during the acute phase of myocardial infarct. Apropos of a further case treated successfully with surgery]. / Une affection curable : la rupture pariétale du coeur à la phase aiguë de l'infarctus du myocarde. A propos d'un nouveau cas opéré avec succès.

A man aged 62 had an unexpected anterior myocardial infarction, complicated during the thirteenth hour after onset by parietal rupture and consequent acute tamponnade. The diagnosis was confirmed by echocardiography and then by pericardial puncture which allowed enough time for an operation to be undertaken under extra-corporeal circulation. The infarct was resected together with the weakened area of rupture, and the quality of the patient's life has been maintained at an excellent level after one year.