Guidelines for quality improvement in cardiac surgery. The College of Cardiac Surgery : results of the 2007 survey.

Optimal delivery of health care is a common goal of individual physicians, professional organizations, hospital structures and governmental authorities. A growing concern has emerged from the public, media and third payer organizations concerning the quality of care and the amount of resources spending. In the United States, large databases, guidelines and performance evaluation have been elaborated by medical societies, particularly in the area of cardiac surgery. These tools are useful for improvement of patients' care, resources distribution, pay for performance and public and practitioners' awareness. The evaluation of quality is based on composite models combining structure, process and outcome indices. However, pitfalls such as patients' selection, and risk avoidance in order to improve results must been prevented by adjustment of the treated populations' risk factors by specific scores. The Belgian Health authorities have built a structure directed at delivery of care improvement based on "Care Programs", monitored by Colleges formed by delegates of professional organizations. The College of Cardiac Surgery has promoted several studies aimed at data collection and evaluation. In 2007, a survey was addressed to all the Belgian Cardiac surgeons to define their opinion as to the best indicators of care in their specialty. These results will serve to define further avenues of research. By maintaining the responsibility of care evaluation in the hands of the involved professionals, this kind of cooperation between governmental and physicians' organizations seems to serve the best interests of the public and the practitioners.

[Sudden onset of hemoptysis during (coil) embolization of a Swan-Ganz catheter induced pseudoaneurysm of the pulmonary artery]. / Survenue d'une hémorragie bronchique lors de l'embolisation d'un pseudo-anévrysme pulmonaire consécutif a un cathétérisme par Swan-Ganz.

We report the embolization of a pulmonary artery pseudoaneurysm consecutive to Swan-Ganz catheterization. Embolization was successful despite an iatrogenic rupture and a massive hemoptysis.

PEEP inhibits hypoxic pulmonary vasoconstriction in dogs.

The effects of an increase in alveolar pressure on hypoxic pulmonary vasoconstriction (HPV) have been reported variably. We therefore studied the effects of positive end-expiratory pressure (PEEP) on pulmonary hemodynamics in 13 pentobarbital-anesthetized dogs ventilated alternately in hyperoxia [inspired O2 fraction (FIO2) 0.4] and in hypoxia (FIO2 0.1). In this intact animal model, HPV was defined as the gradient between hypoxic and hyperoxic transmural (tm) mean pulmonary arterial pressure [Ppa(tm)] at any level of cardiac index (Q). Ppa(tm)/Q plots were constructed with mean transmural left atrial pressure [Pla(tm)] kept constant at approximately 6 mmHg (n = 5 dogs), and Ppa(tm)/PEEP plots were constructed with Q kept constant approximately 2.8 l.min-1.m-2 and Pla(tm) kept constant approximately 8 mmHg (n = 8 dogs). Q was manipulated using a femoral arteriovenous bypass and a balloon catheter in the inferior vena cava. Pla(tm) was held constant by a balloon catheter placed by left thoracotomy in the left atrium. Increasing PEEP, from 0 to 12 Torr by 2-Torr increments, at constant Q and Pla(tm), increased Ppa(tm) from 14 +/- 1 (SE) to 19 +/- 1 mmHg in hyperoxia but did not affect Ppa(tm) (from 22 +/- 2 to 23 +/- 1 mmHg) in hypoxia. Both hypoxia and PEEP, at constant Pla(tm), increased Ppa(tm) over the whole range of Q studied, from 1 to 5 l/min, but more at the highest than at the lowest Q and without change in extrapolated pressure intercepts. Adding PEEP to hypoxia did not affect Ppa(tm) at all levels of Q.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison between muscarinic receptor occupancy, adenylate cyclase inhibition, and inotropic response in human heart.

Binding to muscarinic receptors was compared with adenylate cyclase inhibition in membranes derived from human heart auricles, and with inhibition of the contraction of auricular muscle fibers. In the absence of GTP, agonists recognized two classes of receptors both of which bound antagonists with the same affinity. In the presence of GTP, both classes of receptors for agonists were converted into a single low affinity state. Carbachol and oxotremorine inhibited adenylate cyclase activity by 43%, pilocarpine being less efficient (-28%). The 3 agonists exerted similar inhibitory effects on the inotropic response, in 7 out of 9 preparations of electrically- and norepinephrine-stimulated fibers. Dose-effect curves suggested that spareness (or an amplification mechanism) was implicated in the occupancy of low affinity binding sites by carbachol and oxotremorine (but not by the partial agonist pilocarpine) and the resulting inhibition of both adenylate cyclase activity and contractile force.

A survey of nine years heart transplantation at Erasme Hospital, University of Brussels.

Between March 1982 and March 1991, 225 heart transplantations (HTx) have been performed in 220 patients suffering end stage cardiac disease. Thirteen percent were females and 87% were males. Age range was from 5 to 68 years. The underlying cardiac disease was ischemic cardiopathy in 51.5%, congestive dilated cardiomyopathy in 42%, valvular cardiomyopathy in 3.5%, toxic myocarditis (post-adriamycin) in 1.5% and chronic rejection in 2.5% (retransplantation). Selection of the recipients was done following the currently well established criteria also taking into account the absolute major contraindications for HTx. Due to the still increasing demand of donor organs, currently donor age has been extended up to 50 years for male and 55 years for female donors. One quarter of the grafts were harvested on site in our institution, two other quarters were harvested somewhere else in Belgium and the last quarter provided by other countries cooperating with Eurotransplant. All patients have undergone orthotopic cardiac transplantation using the standard Lower and Shumway technique. Immunosuppression protocols have changed four times throughout the years. Nevertheless all were based on the use of Ciclosporine variously combined with other current immunosuppressive drugs. Rejection monitoring relied on routine endocardiac biopsy and was diagnosed according to the Billingham criteria. The in-hospital mortality is currently 11%. Infection, early right heart graft failure and acute rejection were the leading causes of death. The major causes of early morbidity were several curable infections, reversible rejection episodes, transient acute renal failure and controllable arterial hypertension. Among the survivors followed for at least one month up to nine years, half of late mortality was caused by chronic rejection followed by infection, sudden death, metabolic disorders, stroke and malignancy. Late morbidity involves cases of mild coronary graft diseases, biological renal insufficiency, some degree of arterial hypertension, dislipidemia. Current actuarial survival rate is 87% at one year, 76% at 5 years up to 9 years. Our experience confirms that HTx represents today and effective therapy for selected patients suffering end stage cardiac disease.

Absence of cardio-depressant effects of CGP 17582 B, a new beta-blocking agent, in patients after coronary surgery.

The hemodynamic effects of CGP 17582 B, a new cardio-selective beta-blocking agent with moderate intrinsic sympathomimetic activity and minimal effects on myocardial contractility, were studied in patients after cardiac surgery for coronary artery bypass graft. Each patient had been treated preoperatively with beta-blocking agents and had a cineangiographic left ventricular ejection fraction between 40 and 60%. Fourteen patients were randomized to receive either 10 mg of propranolol or 50 mg of CGP 17582 B orally. Both drugs resulted in a significant and a similar decrease in heart rate. However, this was associated with a significant decrease in stroke volume after propranolol but not after CGP 17582 B, so that cardiac output significantly decreased only after propranolol. Thermodilution right ventricular ejection fraction significantly decreased after propranolol but not after CGP 17582 B. Each drug was well tolerated during the 10 following days and the recovery was uneventful in each patient. These results indicate that CGP 17582 B is a promising beta-blocking agent susceptible to reduce heart rate without altering cardiovascular function after cardiac surgery.

Conversion from ministernotomy to full sternotomy in aortic valve replacement.

Conversion (C) from ministernotomy (M.S.) to full sternotomy was necessary in 5% of the cases in a series of 100 patients consecutively operated for Aortic Valve Replacement (A.V.R.) Analysis of the demographics and surgical techniques indicate older age, aortic fragility, diffuse coronary disease, chronic renal failure and left vent insertion as contributing factors. Despite increased operative blood losses, extra-corporeal circulation (E.C.C.) times, intensive care unit (I.C.U.) stay and hospital stay, no mortality was observed in the conversion group, as compared to 4.2% mortality in the total ministernotomy (MS) population. Preoperative patients selection, avoidance of technical pitfalls, and knowledge of alternative surgical measures are suggested to further decrease the incidence of conversions.

[Continuous emission Doppler study with spectrum analysis in the evaluation of aortic stenosis in adults. Apropos of 30 cases]. / Le Doppler à émission continue avec analyse spectrale dans l'évaluation des sténoses aortiques de l'adulte. A propos de 30 cas.

The value of continuous wave doppler with spectral analysis for the evaluation of aortic stenosis in adults being controverted, we analyzed prospectively the results obtained in 30 consecutive elderly patients (mean age 63 years) investigated by invasive and non-invasive methods. In 24 patients who underwent both ultrasonic and catheter examinations, the correlation between mean gradients measured by catheterization and calculated separately by doppler was 0.80. For a semi-quantitative evaluation of the aortic valve area, we suggest to use an additional severity index R calculated from doppler data (R = mean gradient/maximal instantaneous gradient) which correlated well (r = -0.68) with the aortic valve area. In our experience, this index makes it possible to separate patients with a less than 0.75 cm2 aortic valve area, as calculated from Gorlin's formula (R greater than 0.65) from patients with a more than 0.75 cm2 aortic valve area (R less than 0.65), irrespective of the associated cardiac index. It is concluded that the doppler ultrasound method provides a highly satisfactory evaluation of transaortic gradient, as well as a semi-quantitative evaluation of the stenotic aortic ostium in the majority of elderly patients with aortic stenosis.

Results of mitral valve reconstruction. Experience of Hôpital Erasme, ULB, Brussels.

BACKGROUND: Reconstructive surgery of the mitral valve has been an alternative to mitral valve replacement in patients with mitral regurgitation. In order to evaluate the early results of mitral valve reconstruction, 38 consecutive cases were analyzed. METHODS: Between January 1985 and May 1993, 38 patients with mitral valve incompetence were treated with a system of reconstructive techniques. Nineteen (52%) of the patients were in NYHA functional class II and seventeen (45%) in class III or IV preoperatively. The cause of the mitral disease was degenerative in 25 (66%), rheumatic in 6 (15%) and ischaemic in 5 (13%) patients. Isolated mitral valve repair was performed in 25 patients (66%); the remainder underwent associated procedures that included a myocardial revascularization in 9 patients (23.6%). Thirty-eight patients (100%) underwent a ring annuloplasty. Resection of the posterior leaflet was performed in 24 patients (63%). RESULTS: There was one operative death (2.6%) and two late deaths (5.3%). Postoperatively, four patients sustained embolic events (incidence 10.5%). Six patients (15.8%) were precociously reoperated within the following month; two patients required valve replacement, one had mediastinitis and three other ones needed a pericardial drainage. Patients routinely received acenocoumarol anticoagulation for two months. Mean follow-up was 33 months (range 6 to 104) and one patient was lost to follow-up. Two years actuarial survival was 91.4%. There were no thromboembolic complications in the follow-up period. No patient was reoperated for valvular insufficiency beyond this time limit. One patient had late endocarditis and has been reoperated for mitral replacement (2.6%). After surgery, 34 survivors (89.5%) were in the NYHA functional class I or II. CONCLUSIONS: These results demonstrate that mitral valvuloplasty is associated with lower operative mortality rates. Preservation of the mitral valve mechanism raised the performance of the left ventricle after reconstructive surgery. The incidence of reoperation and thromboembolism was low.

[Extensive intramural hematoma of the thoracic aorta]. / Hématome intramural extensif de l'aorte thoracique.

A[TRACE;del] 53-year-old hypertensive patient presenting with acute chest pain was found to have an intramural haematoma (IMH) of both ascending and descending aorta associated with a 6 cm ascending fusiform aortic aneurysm. Six weeks of antihypertensive treatment allowed complete resolution of the intramural haematoma of the descending aorta. Limited surgical repair of the ascending aorta by Gore-Tex graft prosthesis interposition was then performed. The patient was in good health with a one-year follow-up.

[Functional non-invasive cardio-respiratory evaluation a month and a year after orthotopic heart transplantation]. / Evaluation fonctionnelle cardio-respiratoire non invasive un mois et un an après transplantation cardiaque orthotopique.

Cardio-respiratory stress tests of 14 patients, performed one month and one year after orthotopic heart transplant, are compared in order to demonstrate the functional and metabolic improvements of their adaptation to stress. At maximal stress, we note a 33 p. cent increase of the oxygen consumption (p 0.001), an 11 p. cent increase of the heart rate (p 0.025) and an 18 p. cent increase of the systolic arterial pressure (p 0.005). Respiratory quotients and respiratory equivalent for oxygen are significantly lower (p 0.008) while there was no significant variation of ventilation/minute, respiratory rate, and the normal capacity. At the sub-maximal level, the only significant differences observed are the decrease of the respiratory quotient (p 0.01), the ventilation/minute (p 0.025), the respiratory equivalent for oxygen (p 0.005) and the respiratory rate (p 0.03). The improvement of the physical condition observed in heart transplants seems related to a better peripheral adaptation to stress (lower respiratory quotients, reflection of the decreased demand on anaerobic metabolism) permitting a lesser demand on the ventilatory response to stress.

[Role of transesophageal echocardiography in the diagnosis of pulmonary embolism]. / Apport de l'échographie cardiaque transoesophagienne au diagnostic d'embolie pulmonaire.

The authors report a 72 year-old woman presenting with severe shock after ilio-femoral artery bypass surgery. The transesophageal echocardiography allowed the diagnosis of an unsuspected massive right pulmonary artery embolism. This case emphasizes the role of this procedure for the early bedside diagnosis of massive pulmonary embolism, especially in critically ill patients who require urgent therapeutic interventions.

[The heart surgery department]. / Le Service de Chirurgie Cardiaque.

The initial development of cardiac surgery at Erasme Hospital was closely related to the achievements in thoracic organ transplantation, with numerous synergies between other clinical and research units of the Faculty of Medicine. New advances in biology and biotechnology have met the challenges of modern cardiology, in the fields of advanced heart failure, refractory angina, rhythm disturbances or minimally invasive surgery. Fundamental aspects of clinical practice have been the subject of laboratory investigations, resulting in fruitful interactions and promising scientific outlooks.

[Traumatic rupture of the isthmus of the thoracic aorta (midterm results in a series of 15 cases)]. / Rupture traumatique de l'isthme de l'aorte thoracique (résultats à moyen terme sur une série de quinze cas).

The authors present a series of 15 cases of traumatic disruption of the aortic isthmus. There were 9 cases of acute rupture and 6 of chronic rupture. All the patients have been operated on. Different technics was used to protect the viscera during aortic cross-clamping, partial E.C.C. in 9 cases, clamp-repair technic in 4 cases and a GOTT shunt in 2 cases. 4 patients died in the first thirty days (3 acute and 1 chronic). 2 cases of paraplegia was observed. All the patients have been reviewed after a mean follow-up of 36 months and remain well but one who is still paraplegic. Surgical repair is mandatory in acute and aortic disruption with a great attention to the associated injuries.