Complete denervation of the heart (autotransplantation) for treatment of severe, refractory coronary spasm.

A 49 year old man had severe refractory Prinzmetal's variant angina and angiographically documented coronary arterial spasm of a dominant circumflex artery. The spasm was provoked by methergine (an ergot alkaloid) and seemed resistant to various forms of medical therapy including administration of nitrates, nifedipine, verapamil, diltiazem and amiodarone. The attacks of angina at rest persisted at the rate of 7 to 15/day and were frequently associated with atrioventricular (A-V) block. After unsuccessful plexectomy performed in another institution, the patient underwent complete cardiac denervation (produced by autotransplantation). The follow-up data have interesting implications in relation to treatment of refractory variant angina, as well as possible mechanisms of coronary arterial spasm.

Banking of cryopreserved heart valves in Europe: assessment of a 10-year operation in the European Homograft Bank (EHB).

BACKGROUND AND AIM OF THE STUDY: The preparation, banking and distribution of cryopreserved heart valves has been carried out at the European Homograft Bank (EHB) in Brussels without interruption since January 1989. We present an assessment of the Bank's activities during this 10-year period. METHODS: Heart valve donors aged <62 years form three categories: multiorgan donors with non-transplantable hearts; recipients of cardiac transplantation; and non-beating heart cadavers with a warm ischemia time of less than 6 h. Past history and biology are checked for transmissible diseases. Dissection, incubation in antibiotics and cryopreservation in 10% dimethylsulfoxide with storage in liquid nitrogen vapors (about -150 degrees C), and quality control are according to the standards of the Belgian Ministry of Health. Cryopreserved valves are shipped to the implantation centers in a dry shipper at about -150 degrees C. RESULTS: Between January 30th 1989 and December 31st 1998, 1,817 non-transplantable hearts and 12 excised semilunar valves were obtained. In total, 2,077 valves (1,032 pulmonary, 931 aortic and 13 mitral) were decontaminated, cryopreserved and stored in liquid nitrogen vapor (six more valves were refrigerated). In total, 1,515 valves were discarded at different stages of the protocol, the main causes of rejection being significant macroscopic lesions (68.2% aortic and 26.67% pulmonary). Inadequate excision at procurement (10.37% pulmonary), persistent contamination after antibiotics (5.6%) and positive serology for hepatitis B and C and Q fever (5.4%) were other frequent causes for rejection. Among the 2,117 accepted valves, 1,398 were graded first and 719 second choice, mainly on the basis of morphology. In total, 2,090 cryopreserved valves and one refrigerated valve were implanted in 39 institutions between May 1989 and December 1998. Of requests, 10.02% could not be satisfied. In total, 967 pulmonary valves were implanted in the right ventricular outflow tract (RVOT); 424 during a Ross procedure, and 76 in the left ventricular outflow tract (LVOT). Of the aortic valves, 732 were implanted in the LVOT and 266 in the RVOT. Mitral homografts were used for tricuspid valve replacement in two cases, and in the mitral position in seven. Complications at distribution and thawing included 10 bag ruptures and 16 transversal conduit wall fractures. Of the valves shipped, 317 (13.16%) were not used and were returned safely in the dry shipper. Comparison of distribution rates in the first 5.5 and last 4.5 years of EHB activity shows: (i) a significant increase in pulmonary valve implantations in the RVOT (from 71.95% to 81.95%); and (ii) a marked increase (265%) in pulmonary homograft implantations as part of a Ross operation, and a significant decrease (28%) in aortic homograft implantation in the LVOT. CONCLUSION: While macroscopic lesions of procured aortic valves remain the most frequent and unavoidable cause of homograft rejection during quality control, the high percentage of inadequate surgical heart valve excision should be corrected. The rates of bacterial contamination and positive serology seem acceptable. Storage and shipping of cryopreserved homografts in liquid nitrogen vapor permits them to be spared very efficiently. The increasing use of pulmonary valves for RVOT reconstruction either in congenital heart disease or as part of the Ross procedure compensates for the limited availability of good quality aortic valves.

Cold blood cardioplegia and warm cardioplegic reperfusion in heart transplantation.

The major cause of early death after heart transplantation is graft failure. In 99 consecutive heart transplantations two protocols of myocardial protection were employed. In group 1 (n = 38) initial cold crystalloid cardioplegia combined with cold saline storage and peroperative surface cooling was used. In group 2 (n = 61) cold crystalloid cardioplegia was injected initially and cold blood cardioplegia (Buckberg) was infused every 30 min as soon as the graft arrived in the operating room. No surface cooling was used. Warm blood cardioplegic reperfusion was administered before removal of the aortic clamp. There were 8 early (within 30 days) deaths in group 1 and 6 in group 2 patients. In group 1 there were 5 cardiac deaths against 3 in group 2. Mean ischemic time was 153 +/- 37 min in group 1 and 158 +/- 51 min (p greater than 0.05) in group 2. The post-transplantation need for catecholamines was ten times higher in group 1 patients than in group 2. The first endomyocardial biopsy (after 1 week) showed cytologic lesions compatible with ischemia in 40% of group 1 and only 9% in group 2 patients. We conclude from this initial experience that intermittent cold blood cardioplegia and warm blood cardioplegic reperfusion are useful in heart transplantation in restoring the damage suffered by the graft during brain death and graft storage.

Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorius myoplasty.

Thirteen myoplasties using the sartorius muscle were performed on 12 patients from 1980 to 1985 for "healing problems" in the groin with subjacent synthetic grafts. Persistant aseptic lymphorrhea was the indication for 4 patients. In 3 other cases, bacterial cultures from the wound were positive. In 2 other patients there was clinical evidence of sepsis with purulent discharge from the wound and an exposed graft. In 3 cases myoplasty was used as a preventive measure after reoperation on patients in poor general condition. Follow-up extends from 3 to 54 months. There was only one recurrence observed at 19 months which was successfully treated by segmental resection of the infected graft and insertion of a new prosthesis through the obturator canal. No recurrence was observed among the other patients as judged by clinical observation and biological tests for inflammation, echotomography, CT scan and indium scintigraphy. The treatment of choice for an infected prosthesis should be removal of the graft and extra-anatomic bypass in the majority of cases. However in some situations, excision of the wound and myoplasty using the sartorius muscle may be of some value and needs further evaluation.

Acute traumatic rupture of the thoracic aorta: place of delayed surgical repair.

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered as an emergency which requires immediate surgery. However surgical mortality is high with an average of 20% in the literature. Twenty seven patients were observed from 1973 to 1986. Three patients were not operated upon (Group I), twenty patients had immediate surgery (Group II) with 60% mortality, four patients underwent delayed surgery (Group III) with 25% mortality. Analysis of cause of death show that associated lesions were present in 72% of pts who did not survive and in only 37% among survivors. Associated lesions may be lethal initially (e.g. brain trauma) or they may be aggravated by the thoracic procedure. Complications from associated lesions may also compromise the outcome. It is well known that the majority of deaths from ATRTA occur within 24 hours. Immediate repair of the aortic lesion should be the rule when aortic rupture is isolated or associated with moderate injuries. It may be however that in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.

The place of cardiac denervation in the surgical treatment of Prinzmetal variant angina.

Coronary artery spasm has been described as occurring frequently in Prinzmetal variant angina. The relatively poorer results obtained after aorto-coronary by pass grafting carried out in patients with Prinzmetal angina may be due to recurrence of spasm despite the grafts. Accordingly it has been our recent policy since February 1973 to carry out cardiac denervation in all patients with Prinzmetal variant angina. The patients fall into two groups depending on the presence or absence of organic disease in the coronary vessel. The technique of cardiac denervation (plexectomy) as described by Arnulf is fully described and the early and late results of this procedure in the two groups are documented and discussed.

Air-borne contamination hazard in open heart surgery. Efficiency of HEPA air filtration and laminar flow.

Since 1975 we have reinforced all measures to prevent post-operative infection in open heart surgery. The environment where we worked has been gradually improved first in our old Hospital and later in the new University unit. It was, therefore, possible to relate post-operative infection to our surroundings and four groups of patients operated upon under different stages of asepsis in the operating theatre were examined. We conclude that air-borne contamination during the operation is a definite hazard, and that HEPA filtration is quite efficient in reducing this risk.

Chronic traumatic aneurysms of the descending thoracic aorta (19 cases).

From 1973 through 1983, 19 cases of chronic traumatic aneurysms (CTA) were observed. Initial trauma was well documented in every case. Patients mean age at time of trauma was 22; mean age at time of surgery was 34. Sixty per cent of patients had no apparent thoracic injury at time of trauma. Ninety-five per cent had associated injuries. Ten/nineteen were asymptomatic. Eighteen were operated on. Rupture was complete in 11, partial in 7. One of the partial ruptures was a simple scar on the aorta. Eighteen were located at the site of the aortic isthmus, one was at level T8-T9. Seventeen had a prosthetic dacron graft sutured from inside the aneurysm. The case where a simple scar was found had a dacron wrapping. Spinal cord protection was used in all cases except in one who was already paraplegic preoperatively. Various shunts were used in 12 cases; 1 patient in the by-pass group had paraplegia. CTA is not a benign disease and all cases, even asymptomatic, should be operated on with a very low risk of mortality (0/18). Occurrence of paraplegia still remains a possible complication although the risk of spinal cord ischemia seems lower than in arteriosclerotic dissecting aneurysms. We favour the "old" technique of temporary dacron shunt graft in CTA for simplicity and easy assessment of function ot the shunt.

[Long-term survival in persons with cardiac pacemakers. Study based on 1,159 patients, 499 with regression at 4-10 years]. / Sopravvivenza a lunga scadenza in portatori di stimolatori cardiaci. Studio basato su 1159 pazienti di cui 499 con un regresso compreso tra 4 e 10 anni

Analysis of the long-term survival of pacemaker carriers showed a parallelism between two curves: that of the survival in patients treated with a pacemaker as from the second month, and that of a control group with the same age and physical structure. Treatment in the first few years was made problematical by defects in surgical technique: while in 17% of reoperations, the reason was straightforward substitution of the pacemaker owing to wear on the battery, 83% were the consequences of complications. Of these, 23% consisted of shifts in the intracavitary probe, electrode failures, or increase in the threshold. The frequency of infections due to implantation or reoperation was 7,4%, in certain cases with fatal outcome. Bearing in mind that mortality from Adam-Stokes disease was 50% prior to the introduction of pacemakers, it can be maintained that this therapy represents a considerable step forward in cardiology. Mortality was 27% in all patients submitted to implantation.

[Short- and mean results of mitral and aortic valve replacement with a Björk-Shiley disc prosthesis. Thromboembolic and hemorrhagic complications]. / Résultats à court et moyen terme du remplacement valvulaire mitral et aortique par prothèse à disque de Björk-Shiley. Les accidents thrombo-emboliques et hémorragiques.

96 patients with a Björk aortic valve and 112 patients with a Björk mitral valve were followed up for four and a half years and five years after operation respectively. The actuarial survival rate was 82.5% in the aortic and 73% in the mitral patients. Late death was observed in 7.3% of mitral patients with thromboembolic complications and 4.2% of mitral patients with left ventricular dysfunction, compared to 2.6% of aortic patients with thromboembolism and 3.6% with left ventricular dysfunction. The incidence of thrombolic complications was three times as great with the prosthesis in the mitral position. The probability of absence of thromboembolic complications, studied by actuarial methods, was 93% at 4 1/2 years in aortic prostheses compared to 82% at 5 years in the mitral prostheses. 12 haemorrhagic complications (5.7%), with one fatality, were observed. Aortic valve replacement with a Björk prosthesis is a very satisfactory operation and the results compare favourably with other prostheses. However, the risk of thromboembolic complications should be seriously considered in the surgical indications when this prosthesis is to be used for mitral valve replacement.

[Aneurysm of the ascending aorta and aortic insuffiency]. / Anévrysmes de l'aorte ascendante et insuffisance aortique

Basing themselves on 24 cases of aneurysm of the ascending aorta with gross aortic incompetence, the authors give an account of their personal experience of this condition. They emphasise: -- the problems of aetiology posed by this annular dilation of the aorta with its associated elastic tissue dystrophy which is seldom apparent except at histological examination of the aortic wall at percuaneous biopsy; --the operative problems which confront the surgeon, especially because the orifices of the coronary vessels are in the very centre of the aneurysm. The detail their modest surgical experience, and emphasise the advantages of using Bentall's operation systematically; it seems that this is likely to be the operation of choice in the future.

[False aneurysms extending from true aneurysms of the left ventricle]. / Les faux anévrysmes développés à partir d'anévrysmes vrais du ventricule gauche.

Over a 10 year period, four cases of post myocardial infarction pseudo-left ventricular aneurysm were observed, two directly arising from the infarct (postero diaphragmatic patients had pseudo-aneurysms which arose inferiorly from true anteroapical aneurysms and underwent surgical resection. Apart from the histological features, a certain number of diagnostic signs merit review: --A clinical course marked by a number of phases (myocardial infarction--pericardial syndrome--true aneurysm complicated or not by arrhythmias--period of stabilisation followed by deterioration due to rapid progression of cardiac failure). -- "Angiographic-like" ultrasonic and isotopic methods complement left ventriculography which confirms the parietal aneurysm and may show three very suggestive signs of pseudo-aneurysm: a narrow communication with the true aneurysm; delayed and prolonged filling of the bulge; inferior extension with localization by pericardial adhesions. Surgery is imperative, the main problem being the extent of resection of the true aneurysm. This is related to the rigid or calcific character of the neck of the pseudo-aneurysm.

[Surgical treatment of Prinzmetal's angina pectoris by plexectomy associated with aortocoronary bypass. Apropos of 56 cases]. / Traitement chirurgical de l'angine de poitrine de Prinzmetal par plexectomie associée au pontage aorto-coronaire. A propos de 56 observations.

The results of coronary bypass surgery are generally not as good in Prinzmetal angina as in classical angina pectoris. The percentage of myocardial infarction, recurrent angina and death is much higher. One reason for these failures could be the persistence of coronary spasm. In order to prevent this, denervation of the pre-supra and retro aortic nerve plexuses was carried out in 56 patients (54 male, 2 female) with Prinzmetal angina and operable coronary arterial lesions. Forty patients had documented coronary spasm mainly of the left anterior descending (20 cases) or the right coronary artery (13 cases). Surgery consisted of cardiac denervation associated with direct myocardial revascularisation by implantation of I (37 cases), 2 (13 cases) or 3 (6 cases) aorto coronary bypass grafts. Two deaths were observed in the perioperative period (one low output syndrome and one severe arrhythmia) and one myocardial infarction in the postoperative period. Of the 54 survivors, 49 are asymptomatic and 2 have recurrent spontaneous angina. Exercise electrocardiography in 44 patients was negative in 40 cases. Continuous electrocardiographic recordings (Holter method) in 33 patients was negative for ischemia and of 25 bypass grafts controlled, 24 were patent. Seventy five methylergometrine provocation tests were performed: only 2 were positive, both in patients with recurrent attacks. Therefore, with respect to the total numbers of recurrent angina (2), post operative infarction (I), peri and post operative deaths (3), the percentage of poor results was only 10,7 p. 100, almost three times lower than in previously reported series. In conclusion, we can say that the association of cardiac denervation with coronary bypass surgery significantly improves the percentage of good results (89,3 p. 100 of patients presenting with Prinzmetal angina).

[Cardiac stimulation in children. A multicenter study of 241 patients]. / Stimulation cardiaque de l'enfant. Etude multicentrique de 241 patients.

This study analyses the results of cardiac pacing in 241 children operated between 1965 and March 1982 in 9 french cardiac centres. The ages at primary implantation were: less than 5 years, 32.8 p. 100, 6 to 10 years, 33.6 p. 100 and 11 to 16.5 years, 33.6 p. 100. Atrioventricular block was congenital in 40.7 p. 100 of cases (98 children) and postoperative in 56.4 p. 100 (136 children) with 67 cases, after repair of isolated ventricular septal defect and 18 after repair of an endocardial cushion defect. The symptoms preceding pacing were syncope (67 cases), bradycardia (92 cases) and cardiac failure (33 cases). The electrocardiographic indications were third degree block in 66.8 p. 100 of cases. The pulse generators were usually implanted in the abdominal wall (71.8 p. 100). The power sources in service (August 1982) were lithium (74 p. 100) and isotopic batteries (26 p. 100). Myocardial electrodes were used in 93.4 p. 100 of cases; 82.2 p. 100 were made by Medtronic. Early problems included: infection (10 cases), displacement of endocavitary electrodes (3 cases), elevated thresholds (2 cases). The late problems encountered were due to fracture of the pacing electrodes (19 cases) and elevated thresholds (50 cases). Two hundred and seven children are alive and well. A total of 341 pulse generators were implanted, 90 p. 100 being VVI mode. In August 1982, 56.6 p. 100 were programmable or multiprogrammable. Despite the technical problems involved, the myocardial approach is still used with good results, especially in young children and babies. The endocavitary approach is an alternative after 5 years of age.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of a severe coronary artery spasm, refractory to complete denervation of the heart (autotransplantation)]. / Traitement d'un spasme artériel coronaire sévère, réfractaire par dénervation complète du coeur (autotransplantation).

The case reported is that of a 49 year old man with very severe Prinzmetal angina due to spasm of the left circumflex artery. Despite intensive medical treatment he continued to suffer frequent attacks with atrioventricular block. As plexectomy was not possible in this case, complete cardiac denervation was performed. After surgery, he had no further attacks and continuous ECG monitoring showed no ischemic phenomena. Nevertheless, a stress test was still able to induce spasm of the same artery which was painless but associated with ECG changes. Eighteen months postoperatively, resting angina recurred with positive stress tests giving painful attacks. Four hypotheses are discussed: 1) the local factor was very important, with a zone of hyperactivity on the left circumflex artery, 2) one of the mechanisms of coronary artery spasm could be the nervous stimulation of this zone, 3) this zone was insensitive to nervous stimulation after autotransplantation but remained sensitive to methylergometrine, 4) the recurrence of resting angina and painful symptoms on stress testing suggests the possibility of reinnervation of the heart, as has been shown after cardiac transplantation, the autonomic nervous system does not play the role generally attributed to it in the genesis of spasm.

[Cystic adventitial disease of the popliteal artery]. / La maladie kystique adventicielle de l'artère poplitée.

This strange lesion has been described as colloid degeneration, adventitial cyst, adventitial cystic disease, cystic degeneration of the popliteal artery. The disease was also observed in other localizations and the first case, which was described in 1946 by Atkins and Key (I) concerned an iliac artery. Bizard (2) in 1978 reported a case of the common femoral artery. Ejrup and Hiertonn (4) described the first popliteal localization in 1954. Bergan in 1970 reported 40 cases and collected 115 operated cases in Rutherford's Vascular Surgery (5). Usually a young patient complaints from a recent severe intermittent claudication. At surgery a cystic lesion is found into the adventitia of the popliteal artery, containing gelatinous material which may be easily evacuated without opening the lumen of the artery. This lesion is totally different from atheroma and also from medial cystic necrosis as described by Erdheim.

[Intraluminal angioplasty. The viewpoint of the cardiovascular surgeon]. / L'angioplastie endoluminale. Le point de vue du chirurgien cardio-vasculaire.

Transluminal angioplasty has currently acquired a freedom of a city in which the indications still remain to be defined. It is important to control results, to keep in mind the general context of the vascular disease, and to consider that transluminal dilatation is a technique of arterial reconstruction to which the same general principles as for other reconstructive therapies should be applied, particularly in atheromatous disease.

[Value of vasodilators in decreasing the afterload during infrarenal abdominal aorta cross-clamping]. / Intérêt des vasodilatateurs pour diminuer la post-charge au cours du clampage aorto-abdominal sous-rénal.

Adverse effects of aortic crossclamping (A. C. C.) have been shown by a retrospective study and a literature review. A. C. C. results in increased afterload with ensuing left ventricular function alteration and low cardiac index (C. I.). 15 P. T. S. sustaining an operation with A. C. C. below the renal arteries were studied. A Swan-Ganz catheter was positioned with recording of pressures, including radial artery pressure and repeated cardiac output determinations. Prior to A. C. C., vascular filling and nitroprusside (N. P.) infusion improved hemodynamic conditions. Increase of C. I. (1.8 to 2.8 l/mm-1/m2) was observed with important decrease in peripheral vascular resistance (from 2,346 to 1,425 dyne/s-1/cm-5), pulmonary capillary pressure was lowered slightly and heart rate as well as mean arterial pressure remained stable. During A. C. C., rate of N. P. infusion was increased to maintain stable arterial pressure. Hemodynamic improvement observed prior to A. C. C. was maintained.

[The long term results of reparative surgery for aorto-iliac stenosis and chronic obstruction. 563 cases followed up for 2 to 13 years (author's transl)]. / Résultats a long terme de la chirurgie restauratrice des sténoses et oblitérations chroniques aorto-iliaques. A propos de 563 cas suivis de 2 à 13 ans.

The results of surgery for aorto-iliac obliterative arterial disease deteriorate progressively over 10 years to leave only 44% good results, 39% deaths, 3% poor results and 14% amputations. Nevertheless, the quality of the surviving patients is satisfactory with 72% good functional results at 10 years and a permeability rate of 76% of reparative procedures at the same period. It is certain that current improvements having resulted in a decrease in early mortality will affect the long-term results in view of the tendency to horizontalisation of graphs beyond the first six months.

[Acute traumatic rupture of the thoracic aorta. Role of delayed surgical treatment]. / Rupture aiguë traumatique de l'isthme de l'aorte. Place du traitement chirurgical différé.

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered to be an emergency which requires immediate surgery. However surgical mortality is high with an average of 20% in the literature. Twenty-seven patients were observed from 1973 to 1986. Three patients were not operated on (Group I). Twenty patients had immediate surgery (group II) with 60% deaths, 4 patients underwent delayed surgery (Group III) with 25% deaths. Analysis of causes of deaths shows that mortality is mainly due to the severity of associated lesions. Associated lesions were present in 72% of patients who did not survive and in only 37% of the survivors. Associated lesions may be lethal initially (E.G. Brain trauma) or they may be aggravated by the thoracic procedure. Complications from associated lesions may also compromise the outcome of the thoracic procedure. It is well known that the majority of deaths from ATRTA are observed within 24 hours. Immediate repair of the aortic lesion should remain the rule when aortic rupture is isolated or associated with moderate injuries. However, in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.