Surgical treatment of infected composite graft after replacement of ascending aorta.

Infection of a composite graft is a serious complication. However, reports of such cases are rare even in large series. We report our experience with 4 patients in whom infection of a composite graft developed with pseudoaneurysm formation. Two of the patients had Marfan's syndrome and were treated by Bentall procedure and 2 were treated by Cabrol technique for non-Marfan cystic medial necrosis. Staphylococcus epidermidis was detected in 2 patients and Enterococcus in 1. Reoperation was carried out between 1 and 32 months after the first intervention. One patient died of cerebral embolism and 3 remained free of infection 11 to 82 months later. These cases and guidelines for managing abdominal and peripheral vascular prosthetic infection indicate the need for prompt reintervention when infection is suspected from chronic sepsis, septicemia, positive blood cultures, fistula, anastomotic leak, hemolysis, embolism, graft deformity, or false aneurysm. When the organism is isolated, appropriate antibiotic therapy should be administered. All prosthetic material should be removed and all adjacent infected or necrotic tissue excised. Local antiseptic irrigation may be helpful. Dead space around the prosthesis should be filled with well-vascularized transposed pedicled flaps. Antibiotic therapy should be intravenously administered for at least 6 weeks.

Acute traumatic isthmic aortic rupture. Long-term results in 49 patients.

Forty-nine patients who sustained acute traumatic rupture of the aorta at the level of the isthmus were treated in our hospital between 1976 and 1990. Four patients died before surgery and 45 patients were operated upon using a pump oxygenator partial bypass in all but 2 cases (1 clamp and sew and 1 shunt). The tear was circumferential in 33 and partial in 12 cases. Direct suture was used in the 12 partial and in 21 of the circumferential tears. A dacron tube was used in 12 patients. Hospital mortality was 3 resulting from brain damage, prolonged shock before surgery and necrosis of the colon 4 weeks after operation. No paraplegia was observed. There were 2 cases of neurological disturbance (2 spinal cord dysfunction 5 and 8 days, respectively, after surgery). These complications were transient. Among the 42 survivors, 1 was lost to follow-up. The clinical aortic status of the remaining 41 was excellent. Aortic reconstitution as assessed by digital aortic angiography was excellent in the 33 cases examined with 2 exceptions (graft stenosis, false aneurysm). Our experience and review of a large series indicate: the use of a partial bypass with pump oxygenator decreases the probability of medullary ischemia, but the risk of spinal cord ischemia is not eliminated. When intra-abdominal lesions are life-threatening, laparotomy must preceed thoracotomy. Clinical results assessed in long-term survivors are excellent, especially after direct repair.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis.

OBJECTIVE: This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. METHODS: Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. RESULTS: Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. CONCLUSIONS: Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

How to protect hypertrophied myocardium? A prospective clinical trial of three preservation techniques.

Protection of the hypertrophied myocardium during heart surgery is still a controversial matter. We prospectively studied 3 currently available preservation techniques in 60 patients operated on for isolated aortic stenosis. Patients were randomly assigned to one of the following groups: CWB: continuous warm blood cardioplegia ICB: intermittent cold blood with warm blood controlled reperfusion Cryst: intermittent cold crystalloid cardioplegia (SLF11, Biosédra Laboratory, Vernon, France). All groups were matched for age, ejection fraction, NYHA class, aortic valve surface, and operative risk score. There were no deaths. No statistically significant difference was found among the groups in terms of ventilatory support time, ICU stay time, hospitalization or atrial fibrillation occurrence. Blood gases in the coronary sinus at the time of clamp release showed deep acidosis with crystalloid cardioplegia (pH = 7.11 vs 7.39 for CWB and 7.38 for UCB, p < 0.0001) associated with a higher lactate production than in the other groups (1.3 mmol vs 0.5 for CWB and 0.58 for ICB, p < 0.0001). Acidosis was corrected at the end of bypass with no significant differences among groups. CK-MB samples were taken on arrival in ICU, then 6 and 24 hours later. These samples showed much higher levels with cold blood (H6: 70 mcg/l vs 33 for CWB and 45 for Cryst, p = 0.0019). Although the 3 types of cardioplegia may be safely used for isolated aortic stenosis surgery, continuous warm blood cardioplegia appears to be the best choice.

[Coronary bypass in patients with severe left ventricular dysfunction (EF < or = 25%). Apropos of 111 patients]. / Pontage coronaire chez les patients avec dysfonction ventriculaire gauche sévère (FE < or = 25%). A propos de 111 patients.

One hundred and eleven patients with severe left ventricular dysfunction (EF < or = 25%) underwent coronary bypass surgery between January 1984 and December 1994. The selection criteria were based on the measurement of an EF < or = 25%, LVEDP and CI. All patients had angina and 83 had signs of pulmonary oedema or episodes of congestive failure. Patients with valvular disease, left ventricular aneurysms, reoperations, surgery for arrhythmias and prior angioplasty, were excluded. The coronary disease usually involved all three vessels. Seventeen patients had lesions of the left main stem associated with lesions of the right coronary artery. The average number of bypass grafts was 2.6 +/- 1.6 per patient. The average duration of aortic clamping was 60 +/- 19 minutes. Operative mortality (first month after surgery) was 10 patients (9%). The operative risk factors were: gender, stage of cardiac failure, emergency surgery, LVEDP > 23 mmHg (p < 0.05), CI < 21/min/m2 (p < 0.05). The mean follow-up period was 42 +/- months (3 lost to follow-up). Late mortality was 42 patients. The one year actuarial survival was 88 +/- 5.3%, 76 +/- 9% at 3 years, and 56 +/- 18% at 6 years. Long-term functional results were related to: preoperative stage of cardiac failure (NYHA stage IV) and the association of raised LVEDP and low CI. Surgical results remained satisfactory, however, and the surgical indication was justified in selected patients despite severe left ventricular dysfunction in cases usually with stable invalidating or unstable angina, in the knowledge that myocardial deterioration is progressive in the medium-term with a high incidence of cardiac failure.

[What myocardial protection to select for isolated aortic valve replacement? A clinical prospective study of 3 cases of cardioplegia]. / Quelle protection myocardique lors du remplacement valvulaire aortique isolé? Etude clinique prospective de trois cardioplégies.

Isolated stenosis of the aortic valve leads to left ventricular hypertrophy which makes myocardial protection difficult during cardiac, surgery and the choice of optimal cardioplegia remains controversial. The authors compared three protocols of cardioplegia in patients operated for isolated aortic stenosis with left ventricular hypertrophy. Sixty consecutive patients with these criteria were randomly attributed to one of the three following groups (20 in each group): cardioplegia with continuous warm blood; cardioplegia with intermittent cold blood with warm reperfusion; cardioplegia with intermittent cristalloid using SLF11 solution. The preoperative data was comparable in three groups. There were no deaths. Patients undergoing cardioplegia with warm blood came off cardio-pulmonary bypass more quickly (15 mn vs 21 mn for the other groups, p = 0.03). Cristalloid cardioplegia was associated with major acidosis in coronary sinus blood when the aorta was declamped (7.11 vs 7.38 for cardioplegia with cold blood and 7.39 for cardioplegia with warm blood, p < 0.0001) but with a low postoperative CPK-MB rise. Cardioplegia with cold blood induced higher CPK-MB liberation than the other forms of cardioplegia (at H-, 63 mcg/L vs 33 for warm blood and 45 for cristalloid cardioplegia, p = 0.0019). None of the protocols tested prevented myocardial lactate production at aortic declamping. Cardioplegia with warm blood offers therefore the best protection for hypertrophied myocardium during simple aortic valve replacement but it does not maintain strictly aerobic metabolism.

[Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis. A propos of 104 patients]. / Remplacement valvulaire aortique après valvuloplastie aortique pour rétrécissement aortique calcifié. A propos de 104 patients.

Between February 1987 and December 1990, 104 patients (48 men, 56 women) with an average age of 69 years, underwent aortic valve replacement (AVR) after one or several percutaneous aortic valve balloon dilatation. Thirty one patients were in Class II and 73 patients in Classes III and IV. Twenty two patients had angina (16 Class I-II, 6 Class III-IV) and 12 patients had syncope or near syncope on effort. The indications of valvuloplasty were: non-definitive contraindications of surgery or a surgical risk which was estimated to be excessive (46 patients), a personal choice (41 patients). Five patients underwent preoperative dilatation because of the high operative risk; 7 patients refused surgery and 5 patients were operated as an emergency (2 mas-sive aortic regurgitations, 1 left ventricular perforation, 1 cardiogenic shock, 1 endocarditis with cardiogenic shock). The inter-val between dilatation and surgery was on average 472 days. The patients were improved over an average period of 261 days. Apart form the emergency cases, the patients were operated because of restenosis. Surgery consisted of 53 mechanical and 51 bioprosthetic valve replacements. There was an associated procedure in 17 cases (17 single bypass grafts, 2 double bypass, 1 triple bypass graft, 1 left ventricular suture, 1 Bigelow procedure, 2 mitral valve replacements, 1 tricuspid annuloplasty, 1 carotid endarteriectomy, 1 replacement of the ascending aorta, 1 closure of ASD). The operative mortality was 7 patients (6.7%). The operative findings were 8 lesions related to dilatation, mainly valve tears or disinsertions requiring rapid (6 cases) or emergency (2 cases) surgery for massive aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aortic valve replacement in patients over 80 years of age. Short- and medium-term results in 140 patients]. / Remplacement valvulaire aortique chez les patients de plus de 80 ans. A propos de 140 patients, résultats à court et moyen termes.

One hundred and forty aortic valve replacements (AVR) performed between 1986 and 1995 at Rouen University Hospital in octogenarians (52 men and 88 women), including 9 emergency procedures, were analysed. One hundred and fifteen patients had pure aortic stenosis, 25 had mixed aortic valve disease with mainly aortic incompetence. The surgical decision was taken by the patient with the surgeon after an interview, in order to exclude too handicapped or undecided patients. Significant coronary artery disease was observed in 42% of cases. Isolated AVR was undertaken in 74% of cases and associated coronary bypass surgery in 23% of cases. Bioprostheses were used in 90% of cases. The valvular lesions were predominantly those of Monckeberg disease. The operative mortality was of 13 patients (9.3%). Functional recovery was satisfactory in 78% of cases; the average duration of the hospital stay was 12 days. All known risk factors for AVR: age, coronary lesions, cardiac failure, low ejection fraction, aortic regurgitation, were associated with insignificant increases in mortality. The secondary mortality was of 28 patients; 99 patients are still alive 4 to 91 months after surgery. The actuarial survival graph showed a 56.5% probability of 5 year survival. Eighty per cent of survivors live at home without loss of autonomy.

[A case of type I aortic dissection presenting as bilateral lower limb ischemia. Discussion of surgical strategy]. / Un cas de dissection aortique de type I révélée par une ischémie bilatérale des membres inférieurs. Discussion concernant la tactique chirurgicale.

The authors report about one case of type I aortic dissection disclosed as bilateral lower limb ischemia. The rarity of this way of expression of dissections may result in a delay in diagnosis that can be highly pejorative in such diseases where mortality is high without surgical treatment. The timing and tactics of the surgery to be implemented between the cure of dissection and the removal of ischemia is discussed. Lastly the choice of the mode of arterial cannulation in a patient who had had an axillo-bifemoral bypass ten days earlier also makes this case interesting.

[Total anomalous pulmonary venous return in a 61 year-old adult]. / Retour veineux pulmonaire anormal total chez un adulte de 61 ans.

The authors report a case of total anomalous pulmonary venous return successfully treated by surgery in a 61 year-old man. This case is unusual because of the late discovery of this congenital malformation which is usually rapidly fatal in the absence of surgical correction. This prolonged survival can be explained by the large atrial septal defect and the absence of obstruction, to pulmonary venous return and associated malformations. Surgical repair is essential to prevent the development of irreversible lesions of the right side of the heat and the pulmonary arterial bed.

[Traumatic isthmic ruptures of the aorta during the acute phase. Reevaluation of surgical treatment. Thoughts apropos of 47 cases]. / Ruptures traumatiques isthmiques de l'aorte au stade aigu: réévaluation du traitement chirurgical. Réflexions à propos de quarante-sept cas.

From 1976 to 1989, 47 patients with traumatic aortic rupture in the area of the isthmus were seen in our institution; 4 patients died from exsanguination before definitive repair. Forty-three patients were operated on. Most of them (n: 41) underwent repair using partial bypass with pump oxygenator. There were 3 postoperative deaths. No patient developed postoperative paraplegia; 2 patients presented totally regressive spinal disturbances 5 and 8 days after surgery. Two of the 38 survivors were lost to follow-up. Postoperative angiography revealed an excellent aortic result in all cases especially in young patients, except two (1 stenosis, 1 aneurysm). Our experience and a review of the literature indicate some observations: despite rapid transport and evaluation, some patients died from exsanguination before definite repair. Cardiopulmonary bypass and correction of metabolic disturbances may decrease the probability of paraplegia and heparinisation did not increase the risk when orthopedic or abdominal lesions were treated before aortic lesion. Direct repair is recommended as the procedure of choice, especially in young patients, angiographic controls showed excellent results and long term follow-up is very satisfactory.

[Reoperations on heart valve prosthesis. Apropos of 99 cases]. / Réinterventions sur prothèses valvulaires cardiaques. A propos de 99 cas.

From March 1977 to November 1988, 99 patients were reoperated on after a first valvular replacement. Mean delay between the two operations was 53 months (10 days to 18 years). The patients were reoperated on mainly for mechanical disinsertion (30), bacterial endocarditis (25) and thrombosis (18 patients). Operative mortality was 11%, mainly following reoperation for bacterial endocarditis. Mean follow-up (85 patients) was 49 months (6 months-11 years). 75% were alive and doing well 4 years after reoperation and 66% at 6 years. Eight patients needed a third operation with two deaths.

[Assessment of the systematic preoperative insertion of an intra-aortic counterpulsation balloon in patients at high operative risk for coronary artery surgery]. / Bilan de la mise en place systématique d'un ballon de contre-pulsion intra-aortique pré-opératoire chez les coronariens à haut risque chirurgical.

The authors report their experience with pre-operative percutaneous balloon counterpulsation in 75 patients considered to be at high operative risk for coronary artery surgery, mainly because of unstable angina refractory to maximum medical therapy. The criteria to define high surgical risk are reported. The results and the vascular risk in relation to this technique are estimated. Two patients died during the operation, 12 died during the early postoperative phase without any improvement following intra-aortic balloon pumping. The rate and severity of complications of percutaneous insertion of intra-aortic balloon counterpulsation are low and seem to be related to pre-existing arteriosclerosis. The stabilizing effect of this pre-operative insertion on angina, refractory to medical treatment, seems to be justifiable in patients presenting one of the defined criteria.

[Reoperation for heart valve prosthesis. Apropos of 99 cases]. / Réinterventions sur prothèses valvulaires cardiaques. A propos de 99 cas.

From March 1977 to November 1988, 99 patients were reoperated on after a first valvular replacement. Mean delay between the two operations was 53 months (10 days to 18 years). The patients were reoperated on mainly for mechanical disinsertion (30), bacterial endocarditis (25) and thrombosis (18 patients). Operative mortality was 11%, mainly following reoperation for bacterial endocarditis. Mean follow-up (85 patients) was 49 months (6 months-11 years). 75% were alive and doing well 4 years after reoperation and 66% at 6 years. Eight patients needed a third operation with two deaths.

[Ambulatory surgery in pediatrics. The value of caudal anesthesia]. / Chirurgie ambulatoire pédiatrique. Intérêt de l'anesthésie caudale.

Ambulatory surgery appears to minimize lasting psychological upset in children. Patients must be properly selected. It is essential that the children and their parents should have a visit with an anaesthetist prior to the patient's admission. Laboratory investigations should be prescribed at that time after questioning and examining the patient. Caudal anaesthesia is a useful regional technique for postoperative pain relief in children. Sacral canal puncture is carried out after the induction of general anaesthesia. Only a light state of general anaesthesia is required. The local anaesthetic mixture is made of equal volumes of 1% lidocaine and 0.5% bupivacaine without adrenaline. Rapid awakening, early feeding and pain relief increase reliability and comfort.

[Spontaneous rupture of subclavian artery disclosing Ehlers-Danlos disease. A case]. / Rupture spontanée d'artère sous-clavière révélant une maladie d'Ehlers-Danlos. Une observation.

The authors report the case of a 30-year old man who suffered spontaneous rupture of the right subclavian artery. Treatment consisted of carotid-axillary graft since the fragility of the vessel precluded direct suture. The clinical symptoms, together with histological and ultrastructural examinations led to a diagnosis of Ehlers-Danlos syndrome with purely arterial manifestations.

[Use of fiber optics in difficult intubations in young children]. / Utilisation du fibroscope dans les intubations difficiles chez le jeune enfant.

Difficulties in performing laryngotracheal intubation may arise in patients with cervicofacial anomalies, particularly when young children are involved. Technical artifices usually employed in adults, mainly intubation under fibroscopic guidance, cannot be used in these cases. Intubation was performed in three children aged between 3 to 4 years by means of a guide-catheter previously introduced into the trachea by using the fibroscope working canal, a method that is particularly recommended, even in younger children. The type of anesthesia used must be adapted to these circumstances.

[Use of new internal jugular vein catheterization modified by using of a "catheter around the needle" (author's transl)]. / Utilisation d'une nouvelle voie d'abord jugulaire interne en réanimation.

Although widely used, subclavian catheterization has lost popularity to the benefit of internal jugular vein judged more secure. Numerous technics have been described. Since two years we use internal jugular vein catheterization according to the description of Boulanger et al. modified by using a "Catheter around the needle" type device 13 cm long and 1.65 mm wide. 122 patients have experienced 125 catheterizations which were performed on the right side in 96.8 p. cent of the cases. More than 50 p. cent of the patients was conscious at the time of venepuncture. 118 attempts were successful. In 7 cases failure was due either to impossibility of puncture (4 times) or catheterization (3 times). The sole complication was accidental arterial puncture (5 times, 4 p. cent). 4 of them at the time of failure of venepuncture. Training has an important role in the occurrence of failures and complications. They were much more frequent during the twenty first attempts. According to us this technic can reduce incidence of accidental arterial puncture. The risk of pneumothorax is low in spite of the length of the needle. But because of the length and relative stiffness of the catheter the tip is always located in the superior vena cava when the right side has been chosen.