Early and late outcome of skeletonised bilateral internal mammary arteries anastomosed to the left coronary system.

OBJECTIVES: To investigate in a retrospective study the technical aspects of using the in situ bilateral internal mammary arteries (IMAs), with the right IMA (RIMA) used for revascularisation of the circumflex system, and to evaluate early and late outcome. MATERIALS AND METHODS: Between January 1997 and July 2003, 552 consecutive patients underwent grafting of the circumflex artery system with an in situ skeletonised RIMA routed through the transverse sinus (eventually retrocaval). Mean (SD) age was 63.8 (11) years. 331 (60%) patients underwent total arterial myocardial revascularisation. Mean follow up was 26 (9) months. RESULTS: The success rate of skeletonised RIMA grafting to the circumflex branch was 100%. There were 19 (3.4%) in-hospital deaths. Perioperative myocardial infarction occurred in 12 (2.2%) patients. In 155 patients undergoing postoperative angiography, two had an occluded RIMA and a string-like phenomenon was seen in three RIMA and one left IMA (LIMA). Three RIMA and three LIMA had stenotic lesions. The patency rates of RIMA and LIMA were 94% and 97.4%, respectively. Strong predictors of non-functional IMA grafts were a recipient coronary artery diameter of < 1.5 mm (p = 0.022), < 60% stenosis of the recipient coronary artery (p = 0.015), diffuse stenotic lesions of the recipient coronary artery (p = 0.018), and a small IMA calibre (p = 0.0001). Cumulative actuarial survival at three years was 96.4% and event-free cumulative survival was 93.8%. CONCLUSIONS: Use of the bilateral IMAs offers the possibility of constructing various configurations, making total arterial myocardial revascularisation possible with a minimum number of arterial conduits. Use of the skeletonised RIMA through the transverse sinus and eventually retrocavally can reach most branches of the circumflex system and is associated with an excellent patency rate. Patients who received bilateral IMA grafts for left coronary system revascularisation had improved early and late outcomes and decreased risk of death, reoperation, and angioplasty.

A rare case of left ventricular outflow obstruction.

We report a patient with a mass originating from the anterior mitral valve leaflet causing severe left ventricular outflow tract obstruction. Noninvasive imaging provided the best diagnostic tools for diagnosis. Histological findings showed a very rare giant blood cyst of the mitral valve.

[Current experience of myocardial revascularization with arterial bypasses]. / Expérience actuelle de la revascularisation myocardique par pontages artériels.

A considerable amount of experience has been accumulated with arterial bypass grafting of the coronary arteries. Long-term results with the internal mammary artery graft have demonstrated that atheromatous complications are rare, permeability rate is high, post-operative cardiac events unusual and survival improved. These excellent results have encouraged wide use of arterial grafts and incited surgeons to try increasing the number of bypasses with arterial grafts. Current research is aimed at determining the beneficial effect of bilateral grafting and extensive use of the mammary artery with sequential and Y anastomoses. Other analogous arteries, used in situ or as free grafts. The most promising results have been obtained with the gastro-epiploic, the epigastric and the radial artery. Long-term results in patients with venous grafts alone demonstrate that in the future myocardial revascularization surgery will be based on the use of arterial grafts although a consensus on the exact nature and strategy of the operation remains to be established.

Wrapping of aortic grafts by pedicled pericardial flaps.

In cases of ascending aorta replacement, pathologic tissues are often completely excised to ensure better accuracy of anastomosis and to avoid inclusion technique drawbacks. In the technique we describe, aortic repair is performed in an open manner, but sutures are covered by one or two mobilized pericardial flaps. This maneuver can reduce blood loss and protect Dacron grafts from adhesions to adjoining organs.

Superiority of controlled surgical reperfusion versus percutaneous transluminal coronary angioplasty in acute coronary occlusion.

Although percutaneous transluminal coronary angioplasty is successful in more than 90% of patients after acute coronary occlusion, overall mortality remains approximately 10% with higher subgroup mortality (i.e., occlusion of the left anterior descending coronary artery, multivessel disease, age older than 70 years, cardiogenic shock) and early recovery of regional wall motion is marginal. This multicenter report shows that controlled surgical reperfusion in patients with acute coronary occlusion reduces overall and subgroup mortality and restores substantial early contractility. In a survey from six institutions, 156 consecutive patients with acute coronary occlusion documented by angiography underwent surgical revascularization with controlled reperfusion using amino acid-enriched blood cardioplegic solution on total vented bypass. Ventricular wall motion was studied by echocardiography or multiple gated acquisition scan on postoperative days 5 to 7 and scored independently (0 = normal, 1 = mild hypokinesia, 2 = severe hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared with results in 1203 patients with acute coronary occlusion treated by angioplasty in five reported medical series. Surgically treated patients were revascularized at longer ischemic intervals (6.3 versus 3.9 hours, p < 0.05) and had a greater incidence of left anterior descending occlusion (61% versus 43%, p < 0.05), multivessel disease (42% versus 22%, p < 0.05), and cardiogenic shock (41% versus 10%, p < 0.05), with 12 patients undergoing cardiopulmonary resuscitation en route to the operating room. Surgical results were superior in all categories, with overall mortality reduced from 8.7% after angioplasty to 3.9% after coronary bypass (p < 0.05). All surgical deaths occurred in patients with preoperative cardiogenic shock. Regional wall motion recovered significantly (score < 2) in 131 of 150 (87%) surgically treated patients with an average score of 0.9 +/- 0.8 (normal to mild hypokinesia) despite longer ischemic times.

Saphenous bicephalic aortocoronary graft in the treatment of right coronary bifurcation stenosis.

We describe a surgical maneuver suitable for stenosis of the bifurcation of the right coronary artery. The distal end of a saphenous vein graft is prepared to obtain a two-headed shape. The anastomosis achieves enlargement of the bifurcation, providing complete distal revascularization.

[Technical problems during coronary revascularization in case of massive calcified aorta]. / Problèmes techniques rencontrés au cours des revascularisations coronariennes avec aorte massivement calcifiée.

A massively calcified ascending aorta which may make aortic clamping impossible, is a major obstacle to coronary revascularisation surgery. The aim of this study was to demonstrate that by the use of certain technical modifications, these patients can be treated even in multivessel disease. In the author's experience, two patients with this condition underwent complete revascularisation with a good surgical result controlled by angiography. The sites of arterial cannulation were the aortic arch in one case, the brachiocephalic artery and the common femoral artery in the other case. The ascending aorta was not clamped in either patient or used as the origin of the coronary bypass grafts. Myocardial protection was performed by systemic cooling with ventricular fibrillation without cardioplegia. The feasibility of these methods has led to the suggestion of a classification of the aortic wall according to peroperative palpation. This classification would provide indications for the use of technical modifications not only in extreme cases of aortic calcification but also in patients with severe atherosclerotic changes at high neurological risk; it would not, however, interfere with the classical technique of revascularisation.

[Postoperative acute aortic dissection. Apropos of two cases]. / Dissection aortique aiguë post-opératoire. A propos de deux cas.

Aortic dissection after cardiac surgery is a rare complication. The prognosis is often poor: 33-78% of mortality. The study of two cases out of 2100 patients operated upon during the last three years, and the review of the literature, allows to recall the mechanism, the anatomic origin and the different surgical techniques. Early diagnosis is essential. Some preventive techniques may reduce the incidence of the iatrogenic dissections.

Spontaneous dissecting aneurysm of the common iliac artery.

A 52-year-old man sought medical advice for sudden onset of intermittent claudication of the left lower limb after 50 meters walking. Aortography documented a dissecting aneurysm limited to the left common iliac artery. After resection, a prosthetic graft was inserted. Pathology showed that the cause of the dissection was atheroma. Spontaneous dissecting aneurysm of the common iliac artery is rare. Rupture represents the principal hazard. A high index of suspicion should lead to diagnosis as soon as signs of lower limb ischemia, occasionally transient, appear.

[Phrenic nerve palsy after heart surgery. The Bichat Hospital experience]. / Paralysies phréniques après chirurgie cardiaque. Expérience de l'Hôpital Bichat.

The frequency of phrenic nerve palsy varies from 2.5 to 8.3%, according to different authors. Contact of the phrenic nerve with cold (ice or saline) seems to be the most frequent etiology. This study points out that good insulation between phrenic nerve and ice slush, used in the pericardium, results in almost complete disappearance of this complication, which is not a benign one, as emphasized by the two deaths in our series.

[Protection and reperfusion of the myocardium by cardioplegia with blood enriched in aspartate and glutamate. Technique and initial results. Report of 60 cases]. / Protection et reperfusion du myocarde par cardioplégie au sang enrichie en aspartate et glutamate. Technique et résultats préliminaires. A propos de soixante patients.

From 1st November 1987 to 30th September 1988, 27 patients with recent myocardial infarction and 33 patients at high risk of postoperative circulatory failure were operated according to the same protocol. In each case, myocardial protection, at the time of aortic clamping, consisted of an intra-coronary injection of a cardioplegic solution of blood enriched with aspartate and glutamate, administered in 3 phases (normothermic induction, hypothermic induction, normothermic reperfusion) according to the protocol described by Buckberg et al. The operative mortality was 11.6% (7/60) and 46.6% (28/60) of patients did not develop any postoperative complications. It is difficult to draw any conclusions concerning the superiority of the method on the basis of a non-comparative clinical study, but its simple application and its safety appear to be clearly demonstrated.

[Intra-aortic balloon counterpulsation. Percutaneous insertion at surgical units. Apropos of 170 cases]. / Contre-pulsion par ballon intra-aortique. Insertion par voie percutanée en milieu chirurgical. A propos de 170 cas.

From 1st January 1985 to 31st December 1987, an intra-aortic balloon counterpulsation device (IABCP) was inserted in 170 patients: 166 balloons were inserted percutaneously and 4 surgically after failure of the percutaneous route. The indications for insertion of IABCP are classified into 3 categories. Category 1 (N = 28) consists of non-operated patients, category 2 (N = 60) consists of patients in whom IABCP balloons were inserted by necessity before, during of after a surgical operation under cardiopulmonary bypass (CPB) and category 1 (N = 82) consists of patients in whom the IABCP balloons were inserted prophylactically prior to an operation under CPB in patients at high risk. Sixteen patients with a percutaneous IABCP balloon developed a major complication related to the balloon (9.6 +/- 2.3%). The early mortality for the entire population was 49.4 +/- 3.8% (84/170). The mortality was 89 +/- 6% (25/28), 65 +/- 6% (39/60) and 24 +/- 5% (20/80) respectively in categories 1, 2 and 3. In category 3, 56 IABCP balloons (68.3%) were retrospectively considered to be necessary (group A). Nineteen patients in group A died (34 +/- 6%). The mortality observed in the 30 patients in category 2 in whom an IABCP balloon was required during the intra- or post-operative period (group B) was 76.6 +/- 7.7% (23/30). It was significantly higher than that observed in group A (p less than 0.001). However, the retrospective nature of this study prevented any formal conclusions concerning the benefit provided by prophylactic IABCP.

[Surgical treatment of infectious endocarditis on a native valve. Apropos of 71 cases]. / Traitement chirurgical de l'endocardite infectieuse sur valve native. A propos de 71 cas.

The results of surgery in a series of 71 patients operated upon for infective endocarditis on a native valve are presented. The patients' mean age was 35 years; the initial focus of infection was usually located in the mouth and the most frequent pathogens were staphylococci and streptococci. The aortic valve was most frequently involved. Only 26 patients underwent surgery after 40 days of antibiotic therapy; 34 were operated upon in a semi-emergency and 11 in an acute emergency. Pre-operative systemic embolism was common (20 cases), notably in the brain (17 cases), and 11 patients remained with sequelae. There was good correlation between the anatomical lesions found at surgery and the data obtained from pre-operative echocardiography. The operation was performed on one valve in 40 cases, on two valves in 20 cases and on three valves in 11 cases. Bioprostheses were used more often than mechanical prostheses. Hospital mortality was nil in patient who underwent elective surgery; it was 14.7 p. 100 in those operated upon in a semi-emergency and 27.3 p. 100 in those operated upon in an acute emergency. Nine patients developed late complications, mostly within 6 months of the operation; in particular, prosthesis disinsertion occurred in 4 cases, and progression of a pre-existing left cardiac failure was observed in 2 cases. In their conclusions the authors emphasize the reliability of echocardiography and the need for an early operation in cases with haemodynamic disorders in order to avoid severe myocardial failure and, if possible, systemic embolism and its fearsome sequelae.

[An original technic for closure of a postinfarction interventricular communication]. / Fermeture originale d'une communication interventriculaire post-infarctus.

An original technique has been successfully used to treat a case of major interventricular communication consecutive to a recent, wide antero-septo-apical infarction. This technique derives directly from Guilmet's reconstructive aneurysmoplasty used for chronic fibrous aneurysms of the left ventricle. The distended anterior aspect of the left ventricle was resected, the left border of the ventriculotomy was lowered and attached to the healthy part of the septum and the right border was brought over and sutured to the lateral aspect of the ventricle. The interventricular communication was therefore closed and excluded from the left ventricular cavity, thus theoretically reducing the risk of residual shunt. The post-operative period was uneventful.

[A new surgical technic for the treatment of left ventricular aneurysm: the overcoat aneurysmoplasty. Preliminary results. 11 cases]. / Nouvelle technique chirurgicale pour la cure des anévrysmes du ventricule gauche: l'anévrysmoplastie en paletot. Résultats préliminaires. 11 observations.

The classical surgical techniques used in post-myocardial infarction left ventricular aneurysms consist in resecting as much as possible of visible fibrous tissues and closure of the two borders by "U"--shaped sutures supported by a Teflon bond. There are two drawbacks to this approach: resection often involves the surface arterial network which often has a significant role to play in vascularising the remaining myocardium; fibrous, akinetic or dyskinetic zones of the anterior 2/3 of the interventricular septum cannot be resected. The proposed technique consists in limiting the surface of resection and in lowering the left border of the aneurysm as far as the posterior 1/3 of the septum. The septum is then sutured over the aneurysm to the antero-lateral wall of the left ventricle. Ten patients were operated using this technique: there were no operative deaths; preoperative cardiac failure regressed in 4 out of 5 patients; one patient was operated for unstable ventricular tachycardia, the arrhythmias disappeared after surgery; one patient operated during the 3rd week for left ventricular pseudo-aneurysm required intra-aortic balloon pumping and developed episodes of VT which finally resolved.