Enhancement of non-coronary collateral blood flow from the internal thoracic arteries: the theoretical and practical basis of an alternative method of myocardial blood supply.

Non-coronary collateral blood flow arrives to the heart from mediastinal, bronchial, and pericardial channels. These enter the heart through the pericardial reflections surrounding the pulmonary and systemic veins, as well as from the vasa vasorum of the aorta and the pulmonary artery leading to and from the myocardium. Before the advent of cardiopulmonary bypass surgery, surgical bilateral ligature of the internal thoracic arteries (ITAs) was performed in patients with ischemic heart disease to increase the perfusion pressure within the channels leading to the heart. Nowadays, the occurrence of natural collaterals between coronary and extracardiac arteries including the ITAs, the potential hemodynamic effects of ITA ligation, the potential of ITAs for developing important collateral branches, and the current availability of angiogenic growth factors could pave the way for the development of a new field in cardiovascular research aimed at developing an alternative strategy of myocardial blood supply by means of the surgical and biological enhancement of non-coronary collateral circulation.

Stimulated human lamina propria T cells manifest enhanced Fas-mediated apoptosis.

Lamina propria (LP) T cells respond poorly to a proliferative stimulus delivered via TCR/CD3 pathway, but retain considerable ability to respond to a stimulus delivered via CD2 costimulatory or accessory pathway. In the present study, we showed first that unstimulated LP T cells, as compared to unstimulated peripheral blood (PB) T cells, exhibit an increased level of apoptosis which is further increased following CD2 pathway stimulation, but not following via TCR/CD3 pathway stimulation. We next showed that IL-2 had a sparing effect on apoptosis of unstimulated LP T cells in that IL-2 decreased and anti-IL-2 increased apoptosis of these cells; in contrast, IL-2 had no effect on apoptosis of CD2-pathway stimulated cells. Finally, we showed that increased apoptosis of LP T cells induced by CD2-pathway stimulation is inhibited when Fas antigen is blocked by a nonstimulatory anti-Fas antibody. These studies suggest that LP T cells are characterized by increased susceptibility to Fas-mediated apoptosis most due to a downstream change in the Fas signaling pathway. Given that IFN-gamma secretion is significantly increased in LP T cells in which apoptosis is inhibited, this feature of LP T cells may represent a mechanism of regulating detrimental immune responses in the mucosal environment.

[Visceral artery aneurysms. Multiple aneurysmal localization: a case report and literature review]. / Les anévrismes des artères digestives. A propos d'un cas clinique de localisation anévrismale multiple et revue de la littérature.

Visceral artery aneurysms constitute a rare vascular disease, with a risk of rupture associated to a high mortality. Often asymptomatic, they are discovered following a routine radiological examination. We present the case of a 71-year-old patient with multiple aneurysms involving the celiac trunk, the splenic artery, and the common hepatic artery. The surgical treatment consisted of an aortohepatic bypass using polytetrafluoroethylene prosthesis, after exclusion of all the aneurysms. The angiography and postoperative angioscan demonstrated the perfect patency of the prosthesis, totally excluding the aneurysms. Given the variety of presentations and the absence of precise predictive factors, there is no therapeutic consensus so far. Surgery is the first therapeutic choice. Endovascular treatment by angioembolization must be reserved for particular conditions. The purpose of this article is to propose the best therapeutic approach on the basis of evidence in the literature.

[Detection and surgical treatment of induced ventricular tachycardia in postinfarction left ventricular aneurysm].

A clinical case of a patient aged 56 years with postinfarction left ventricular aneurysm not complicated with ventricular tachyarrhythmias is presented electrophysiological investigation. Left ventricular aneurysmectomy supplemented with endocardial cryodestruction was carried out. At electrophysiological investigation after surgery ventricular tachycardia could not be induced. In 2 years postoperatively no ventricular tachyarrhythmias were noted. The condition of the patient is satisfactory, corresponds to NYHA class I.

[Surgery of ventricular tachycardia in post-infarction left ventricular aneurysm]. / Chirurgie des tachycardies ventriculaires sur anévrismes ventriculaires gauches post-infarctus.

The treatment of post-infarction ventricular tachycardias with antiarrhythmic drug therapy, implantable automatic defibrillators, radiofrequency ablation, also includes different surgical procedures such as endocardial resection of the infarct scar, encircling endocardial ventriculotomy and endocardial cryoablation or thermoexclusion by laser. These procedures may be extensive or limited, guided or not by preoperative mapping. The aim of this review of the literature is to update our knowledge of these different surgical techniques and to define their indications.

Recurrence of postoperative aortic fistulas: is there an ideal method of prevention? A case report.

There are very few cases in English literature of recurrent postoperative aortic fistulas (RPAFs). These are neo-communications between the aortic bloodstream and the lumen of contiguous organs which occur after unpredictable periods from surgical treatment of a previous fistula. The supradiaphragmatic aorta may fistulize into the airways, pulmonary circulation, oesophagus, and cardiac chambers; the infradiaphragmatic aorta into the intestine, stomach, and vena cava. According to the etiology, aortic fistulas are categorized as postoperative (or secondary) and spontaneous (or primary), and RPAF may be considered a subgroup of secondary fistulas. They may recur even more times in the same patient, hence the role of prevention is of the utmost importance. The simultaneous respect of different surgical principles is crucial to make the risk of recurrence less likely. Surgical treatment represents a real challenge due to the emergency conditions and redo nature of operations. Mortality rate is very high. In this article, we describe a case of recurrent aorto-duodenal communication, we discuss the principles of prevention both for the supra and infradiaphragmatic aorta, we introduce some modifications to the classic categorization and we present the first RPAF literature review.

Inhaled prostacyclin reduces cardiopulmonary bypass-induced pulmonary endothelial dysfunction via increased cyclic adenosine monophosphate levels.

OBJECTIVE: Cardiopulmonary bypass triggers a systemic inflammatory response that alters pulmonary endothelial function, which can contribute to pulmonary hypertension. This study was designed to demonstrate that inhaled prostacyclin, a selective pulmonary vasodilator prostaglandin, prevents pulmonary arterial endothelial dysfunction induced by cardiopulmonary bypass. METHODS: Three groups of Landrace swine were compared: control without cardiopulmonary bypass (control group); 90 minutes of normothermic cardiopulmonary bypass (bypass group); 90 minutes of cardiopulmonary bypass and treated with prostacyclin during cardiopulmonary bypass (continuous nebulization with continuous positive airway pressure until the end of the cardiopulmonary bypass; prostacyclin group). After 60 minutes of reperfusion, swine were put to death and pulmonary arteries harvested. After contraction to phenylephrine, endothelium-dependent relaxation to bradykinin and acetylcholine was studied in standard organ chamber experiments. The pulmonary artery intravascular cyclic adenosine monophosphate content was compared between the 3 groups (post-cardiopulmonary bypass). RESULTS: There was a statistically significant improvement of the endothelium-dependent relaxation to bradykinin in the prostacyclin group when compared with the bypass group (P <.05). There was no statistically significant difference for endothelium-dependent relaxation to acetylcholine (P >.05) between the prostacyclin and the bypass groups. There was a statistically significant decrease in the cyclic adenosine monophosphate content and a statistically significant increase of the mean pulmonary artery pressure in the bypass group only (P <.05). CONCLUSION: Prophylactic use of inhaled prostacyclin has a favorable impact on the pulmonary endothelial dysfunction induced by cardiopulmonary bypass associated with preservation of pulmonary intravascular cyclic adenosine monophosphate content and the pulmonary vascular tone.

Preservation of three-dimensional annular movement with the SJM-Seguin mitral annuloplasty ring.

BACKGROUND AND AIMS OF THE STUDY: In order to achieve optimal annuloplasty during mitral valve repair, we developed a new device, the SJM-Seguin annuloplasty ring, with the aim of remodeling, correcting dilatation, and preserving physiologic annulus function. This ring has variable flexibility; that is, it is sufficiently rigid in its anterior region to maintain intercommissural distance, yet sufficiently flexible in its posterior region so as not to interfere with left ventricular function and to permit the natural three-dimensional annular mobility. METHODS: Following successful studies in animals, 75 patients were operated on for mitral regurgitation between January 1994 and May 1996. The patients' mean age was 60.4 +/- 13.2 years; 53.8% were men. The cause of mitral insufficiency was degenerative in 77.4% of patients, rheumatic in 12%, ischemic in 5.3%, and infectious in 5.3%. Associated procedures were carried out in 36% of the cases. RESULTS: There were no intraoperative deaths, but two in-hospital deaths and one late death, all of which were unrelated to the annuloplasty ring. Mitral regurgitation, monitored by transesophageal echocardiography decreased from +3.42 +/- 0.6 before repair to +0.31 +/- 0.12 after repair (p < 0.005). Follow up was 100% at a mean of 14.2 months (range: 3 to 26 months). There were no annuloplasty-related complications, and especially no echocardiographically discernible systolic anterior motion. There were no transient ischemic attacks. One reoperation was performed due to endocarditis at nine months after initial repair. The average transmitral gradient was 1.94 mmHg. CONCLUSIONS: This new annuloplasty ring provides, with the absence of any valve-related complications, correction of annular dilatation and remodeling of the annulus while respecting physiologic annulus function such as natural three-dimensional mobility.

Aspergillus flavus mitral valve endocarditis after lung abscess.

A 16-year-old male with bone marrow failure due to chemotherapy for recurrent acute lymphoblastic leukemia developed an abscess in the lower lobe of the left lung draining through a bronchogastric fistula, as well as mitral valve endocarditis with large vegetations. After a course of antifungal therapy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, double-leaflet prosthesis. Microscopy of the lung and heart specimens disclosed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fungus, which was identified by culturing on Czapek's medium as Aspergillus flavus. Despite further antifungal therapy, fatal embolism developed. The emboli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunocompromised patients, and suggests that delayed surgical treatment and the presence of another focus of Aspergillus infection may increase the risk of death.

Simple surgical technique to prevent direct secondary aortoenteric fistulas.

To prevent direct secondary aortoenteric fistulas, a devastating complication of abdominal aortic surgery, we describe here a rapid, very easy to perform and no cost operating technique. A part about 4 cm long of the vascular prosthesis was cut to obtain a partial tailored ring which was passed through the prosthesis. After the anastomosis was realized, the tailored ring was hitched up to totally cover proximal anastomosis and prevent direct contact between aorto-prosthetic anastomosis and the bowel.

Vertebral artery surgery with cardiopulmonary bypass and deep hypothermia.

Deep hypothermia was proposed to prevent neuronal ischemia and stroke during surgical procedures on arteries that supply the brain, especially with extended occlusive lesions on both internal carotid arteries. The interest of this therapeutic option is still under discussion, even in the case of combined cardiac and cerebrovascular surgery. We report the case of a 53-year-old male who was admitted to our institution for symptomatic vertebrobasilar insufficiency. Angiography showed a thrombosis of both internal carotid arteries, stenosis of both external carotid arteries, and a tight proximal stenosis of a dominant right vertebral artery. Endarterectomy and angioplasty of the origin of the right external carotid artery was done first to increase the blood supply to the brain via collateral arteries connecting the extra- and intracranial networks. Six weeks after this, a right-sided vertebral-to-carotid artery anastomosis was performed during cardiopulmonary bypass (CPB)-induced deep hypothermia for optimal neuronal protection, with good results. However, early thrombosis of the right vertebral artery requiring reintervention in normothermia, without any stroke, indicate that deep hypothermia was unnecessary in this case, probably because of the previous natural and surgical development of collateral circulation. However, there was no means of predicting this in a reliable manner before the procedure and deep hypothermia appeared a safe technique for neuronal protection without any specific postoperative complications.

Topical negative pressure therapy. A very useful new method to treat severe infected vascular approaches in the groin.

AIM: The treatment of infected vascular surgery sites is challenging. Negative pressure applied uniformly to the entire wound surface has been shown to allow granulation tissue formation and to promote healing of acute and chronic wounds. METHODS: We used the Vacuum-Assisted Closure (VAC, Kinetic Concepts Incorporated, San Antonio, Texas, USA) system in 4 patients with severe groin wound infection after emergency surgery on the femoral artery. RESULTS: In all 4 patients, general health improved and the wound changed rapidly from a large infected cavity to a minor lesion readily covered using a simple surgical technique. CONCLUSION: This study establishes VAC as a very valuable tool for managing severe complications of groin vascular surgery sites even in patients with obesity and/or diabetes mellitus.

Advance in mitral valve repair using a device flexible in three dimensions. The St Jude Medical-Séguin annuloplasty ring.

To allow remodeling of the annulus while respecting natural three dimensional annular movements during mitral valve repair, a new annuloplasty ring (St Jude Medical [SJM]-Séguin annuloplasty ring) was developed. This ring has variable flexibility; that is, it is sufficiently rigid on the anterior portion to maintain intercommissural distance, and sufficiently flexible on the posterior portion to respect left ventricular function and natural three dimensional annular mobility. Fifty patients operated on for pure mitral regurgitation between January, 1994 and June, 1995 were studied. Mean age was 58 years. The cause of mitral insufficiency was degenerative in 80% of the patients, rheumatic in 12%, ischemic in 4%, and infectious in 4%. The operative technique to restore normal valve coaptation was quadrangular resection in 31 cases, commissurotomy and chordal fenestration in 8, use of polytetrafluoroethylene chordae in 6, and chordal shortening or transposition in 5. Annuloplasty with a SJM-Séguin annuloplasty ring was realized in all 50 cases. Transesophageal echocardiographic mitral regurgitation decreased from 3.6 +/- 0.8 to 0.3 +/- 0.2 after repair (p < 0.005). Two post operative deaths due to non valve related complications, were observed. There were no ring related complications, especially no left ventricular outflow tract obstruction due to systolic anterior motion. Patients were all reviewed at a mean follow-up of 12.1 months (range, 9-27 months). All are well, in New York Heart Association functional Class I. Echocardiography showed a mean 0.4 +/- 0.3 mitral regurgitation, absence of any systolic anterior motion, and satisfactory mobility of the annuloplasty ring after the movements of the natural annulus, including non planar deviation. These preliminary results suggest that this annuloplasty ring 1) provides excellent correction of annular dilatation and remodeling of the annulus, 2) avoids systolic anterior motion observed with rigid rings, and 3) preserves physiologic three dimensional annulus motion.

[Impact of psychiatric disturbances on the outcome of coronary bypass surgery]. / Impact des troubles psychiques sur les suites d'un pontage coronaire.

The influence of anxiety and depression on the development and prognosis of coronary disease seems to be well established but there are few studies of the effects of these disturbances on the postoperative outcome of coronary surgery. The object of this review of the literature was to present recent data on this subject and to suggest therapeutic strategies for patients referred for coronary bypass surgery to improve their quality of life and even cardiovascular prognosis.

[Outcome of type I acute aortic dissection operated after 70 years of age. A retrospective study of operated dissection of the aorta in the over 70 years old]. / Devenir des dissections aortiques aiguës de type I opérées après 70 ans. Etude rétrospective des dissections aortiques opérées de plus de 70 ans.

The aim of this study was to assess the perioperative mortality and long-term outcome of Type I dissection of the aorta operated in patients over 70 years age. Of the 87 dissections of the aorta operated between 1988 and 1995, 19 concerned patients aged 71 to 79 (average 74.1 +/- 2.4 years). The procedure was replacement of the ascending aorta with gluing of the false lumen in call ases. Two patients also underwent aortic valve replacement and three also had replacement or repair of the aortic arch. Eleven patients (56%) had circulatory arrests lasting an average of 33 minutes (10-86 minutes). The mortality rate at 30 days was 31.5% (6/19): 3 deaths were due to bleeding, 1 to mesenteric infarction, 1 to cardiac arrhythmia and 1 to a cerebrovascular accident. The morbidity was 53%, mainly due to neurological complications, chest infection and renal failure. After an average period of 36.8 months (range: 3 to 75 months) with no patient lost to follow-up, the late mortality was 23% (3/13), giving actuarial survival rates at 1.5 and 6 years of 63%, 47.5% and 32%, respectively (including the operative mortality). Or the survivors, 9 were in NYHA Classes I-II and 1 in class III. One patient developed a hemiparesis. The authors conclude that, despite high mortality and morbidity at 30 days, long-term survival and its quality are arguments in favour of surgical management, even in elderly patients.

[Is Dacron carcinogenic? Apropos of a case and review of the literature]. / Le Dacron est-il cancérigène ? A propos d'un cas et revue de littérature.

Primary malignant cardiac tumours are extremely rare. The authors report a case of primary cardiac lymphoma nine years after implantation of a double leaflet mitral valve prosthesis. Malignant lymphoma is a haematological form of sarcoma. Exceptionally rare, it is a tumour of the immune system occurring principally in immuno-depressed patients. It typically presents as a nodular or diffuse myocardial infiltrate explaining its clinical expression as cardiac failure and atrioventricular block. In view of the usual degree of infiltration, surgery is rarely possible. Survival after "pure" medical therapy (chemotherapy alone or associated with radiotherapy) is 6 to 8 months after diagnosis. Dacron has been implicated in the pathogenesis of primary cardiac sarcoma. Oppenheimer demonstrated experimental induction of sarcoma in the rat by subcutaneous implantation of polymers. In conclusion, although primary cardiac lymphoma is a rare condition, it should be considered, as with thrombosis, a possible differential diagnosis of acute dysfunction of cardiac valvular prostheses.

[Cardiac surgery in the octogenarian: what risks for what benefits?]. / La chirurgie cardiaque chez l'octogénaire: quels risques pour quels bénéfices?

About 1 to 8% of patients referred for cardiac surgery in industrialised countries are octogenarians. Hospital mortality is high and depends on age, type of surgery and other predictors of death which are female gender, left congestive heart failure, history of myocardial infarction, chronic obstructive lung disease, renal insufficiency, carotid and others vascular diseases. Morbidity is also very high. Besides supraventricular arrhythmias, respiratory failure is the main cause (20 to 30%) of morbidity, followed by cerebrovascular accident and renal failure. Due to this high rate of postoperative events, the length of stay is significantly increased. At follow-up however, excellent functional status and survival rate is afforded by the operative procedure. The main problem remains the selection of patients in order to improve results.

[Results of coronary artery surgery in octogenarians]. / Résultats de la chirurgie coronaire chez l'octogénaire.

Over an 11 year period from January 1990 to December 2000, 3282 patients underwent isolated or combined surgical myocardial revascularisation. In this group, 42 were aged 80 or over (maximum 87 years), 1.3% of the total patient population. The mean age of this subgroup was 81.8 +/- 1.75 years) with a male predominance (61.9%). All patients were autonomous and considered to be in good general and psychological health. Preoperative coronary angiography showed 33.3% of left main stem lesions either alone or associated with a right coronary lesion. The ejection fraction was over 50% in 78.6% of cases. Saphenous vein grafts were used in all but 5 patients who also had left internal mammary artery grafts. Thirteen patients (31%) underwent combined valvular surgery (11 aortic and 2 mitral valve) and 2 patients underwent combined vascular surgery. Three patients were operated as an emergency. A total of 5 patients died in the first 30 postoperative days, a hospital mortality of 11.9%. There were 2 postoperative hemiplegias and 2 cases of renal failure which were aggravated in the postoperative period. The other patients were discharged from hospital with a satisfactory cardiac and functional status. The global mortality was 14% at 3 years and 18% at 5 years. The main bad prognostic factor for survival was the association of aortic valve surgery. In selected octogenarians in good general and psychological health without severe co-morbid conditions, surgical myocardial revascularisation may be considered with an acceptable operative risk.

[Chronic constrictive pericarditis in African children: report of a case]. / Péricardite chronique constrictive chez l'enfant africain: à propos d'un cas.

The chronic constrictive pericarditis is a rare affection, with multiple etiologies and concerning especially the adult. We report a case of chronic constrictive pericarditis in an African child in whom no etiology was found. A review of the literature raises the characteristics of chronic constrictive pericarditis for a better therapeutic management.