[The left ventricular reconstructive surgery at the origin of the treatment of cardiac insufficiency]. / La reconstruction ventriculaire a l'origine du traitement chirurgical de l'insuffisance cardiaque.

The surgical method of ventricular reconstruction described by Dor is recalled with the clinical report of a patient who presented a ventricular aneurysm. The left ventricular reconstructive surgery is based on an anatomical design of the heart described by Torrent-Guasp, where the normal orientation of the left ventricular muscle fibers, oblique in direction, is found parallel with the base of the heart at the time of ventricular dilation. By giving again an elliptic form to the left ventricle, the left ventricular reconstructive surgery improves the cardiac function of the patient who developed a bulky aneurysm after an infarction. Based on this concept, other techniques of ventricular reconstruction intended for patients presenting dilated cardiomyopathy, of ischemic origin or not, are being studied.

The deletion genotype of the angiotensin I-converting enzyme is associated with an increased vascular reactivity in vivo and in vitro.

OBJECTIVES: To define a link between the deletion genotype (DD) and vascular reactivity, we studied in vivo and in vitro phenylephrine (PE)-induced tone and the effect of angiotensin II (AII) at physiological (subthreshold) concentrations on PE-induced tone. BACKGROUND: The deletion allele (D) of the angiotensin I-converting enzyme (ACE) has been associated with a higher circulating and cellular ACE activity and possibly with some cardiovascular diseases. METHODS: During cardiac surgery PE-induced contraction was studied in patients with excessive hypotension. In parallel, excess material of internal mammary artery, isolated from patients operated for bypass surgery, was mounted in an organ chamber, in vitro, for isometric vascular wall force measurement. RESULTS: In patients under extracorporeal circulation, PE (25 to 150 microg) induced higher contractions in patients with the DD genotype (e.g., with PE 75 microg: 20.3 +/- 2.9 vs. 11.5 +/- 2.5 mm Hg/ml per min, DD vs. II/ID, n = 15 vs. 30, p < 0.03). In the mammary artery, in vitro, contractions to PE (0.1 to 100 micromol/liter) or AII (1 or 100 nmol/liter) were not affected by the genotype. Angiotensin II (10 pmol/liter) significantly potentiated PE (1 micromol/liter)-induced contraction in both groups. Potentiation of PE-induced tone by AII was significantly higher in the DD than in the II/ID group. CONCLUSIONS: The DD genotype was associated with an increased reactivity to PE in vivo and potentiating effect of exogenous AII in vitro. The higher response to PE in vivo might reflect a higher potentiation by endogenous AII. These data should be considered to understand possible link(s) between cardiovascular disorders and the ACE gene polymorphism.

Desmopressin has no beneficial effect on excessive postoperative bleeding or blood product requirements associated with cardiopulmonary bypass.

Cardiopulmonary bypass during open-heart surgery is sometimes associated with excessive perioperative bleeding. Following a non-randomized study suggesting that desmopressin acetate (desmopressin) reduced blood product requirements in these patients, we conducted a double-blind, placebo-controlled randomized trial of desmopressin (0.3 micrograms/kg, i. v.) in 92 patients with overt bleeding and a prolonged bleeding time. Mean blood loss during the first 24 h post-treatment was similar in the desmopressin and placebo groups (582 vs 465 ml, respectively; p = 0.15). Red-cell (p = 0.76), fresh frozen plasma (r = 0.66) and platelet unit (p = 0.74) requirements were also similar. The haemostatic effect of desmopressin has been attributed to the release of von Willebrand factor (vWF) and a reduced bleeding time. In our study, vWF and factor VIII:C levels increased while the bleeding time decreased significantly at 90 min and 24 h in both groups and, although vWF and factor VIII:C levels were slightly higher in desmopressin-treated patients at 90 min, the difference was not significant. Thrombin-antithrombin III complex, fibrinogen degradation product and tissue plasminogen activator levels, reflecting activation of the coagulation and fibrinolytic systems, respectively, decreased uniformly in both groups. We conclude that desmopressin is not useful in reducing blood loss or blood product requirements in patients with excessive immediate postoperative bleeding.

Tetralogy of Fallot with type C complete atrioventricular canal: surgical repair in three cases.

The successful repair of three consecutive cases of tetralogy of Fallot associated with complete atrioventricular canal type C is reported. The correct preoperative diagnosis was established by right and left ventriculography. Operative repair in the first two patients involved division of both hemivalves above the crest of the ventricular septal defect and closure of the septal defects with a single large Dacron patch. In the third patient, the septal defects were closed with two separate patches. The undivided hemivalves were attached to the patches by interrupted sutures placed more to the right side of the midline, so that tricuspid tissue was used to reconstitute the mitral valve. Right ventricular outflow tract obstruction was relieved by infundibulectomy, pulmonary valvulotomy, and placement of a Darcon patch on the infundibulum in Cases 1 and 3. A valved tube was used in Case 2. Six months postoperatively, the condition of the patient is satisfactory. The first patient is receiving digitalis; the second, digitalis and diuretics; and the third patient is well without treatment.

Tandem coarctation of the thoracic aorta. An unusual congenital anomaly.

The coarctation involving the aortic isthmus, with hypoplasia of the upper aortic segment, was satisfactorily repaired in a 15-year-old girl. The technique used was subclavian flap arterioplasty followed by reimplantation of the distal subclavian artery into the left carotid artery. Suprisingly weak femoral pulses were noted postoperatively and prompted a control angiogram. This showed an intraluminal diaphragm 2 cm below the site of the previous repair, with a 100 mm Hg gradient. At reoperation, a centrally performed fibrous diaphragm was excised, and the aorta was enlarged with a small Dacron patch. The postoperative course was uneventful.

Multicenter study of stentless valve replacement in the small aortic root.

OBJECTIVE: A clinical study was conducted to evaluate the results of stentless porcine valves in patients with a small aortic root (19- and 21-mm aortic anulus). METHODS: Of 567 patients, from 4 surgical institutions, 171 patients (30.1%) had a small aortic root, comprising 163 cases with calcified aortic stenosis and 8 cases with predominant valvular insufficiency. Sixty patients had associated mitral or coronary lesions. Mean age was 72 +/- 4.2 years. Forty-seven patients with a small aortic root had a 19-mm anulus, and 124 patients had a 21-mm anulus. The body surface area was, respectively, 1.55 +/- 0.2 m2 and 1.78 +/- 0.45 m2. Hemodynamic evaluation of the stentless valve comprised serial measures of mean gradients, effective orifice area, and left ventricular mass reduction. Complication rates for secondary events were evaluated over a 6-year period. RESULTS: The hospital mortality rate was 3.5%. The mean gradients after the first year were 9 +/- 2 mm Hg and 6 +/- 1.7 mm Hg in patients with a 19-mm and a 21-mm anulus, respectively. Effective orifice area was 1.45 +/- 0.3 cm2 and 1.72 +/- 0.4 cm2. Gradients and surfaces remained stable throughout the study period. Aortic regurgitation was zero to trace. Left ventricular mass at discharge and at 1 year were, respectively, 296 +/- 127 g and 215 +/- 102 g for patients with a 19-mm anulus and 281 +/- 75 g and 236 +/- 15 g for patients with a 21-mm anulus. CONCLUSIONS: Stentless valves are a suitable device for elderly patients with small aortic roots, which leave only mild residual obstruction.

Recurrent coarctation of the thoracic aorta: subclavian flap arterioplasty with carotid reimplantation of the distal subclavian artery.

Combining a subclavian flap procedure and reimplantation of the distal subclavian artery into the left carotid artery was used in 2 patients with recurrent coarctation of the thoracic aorta. One of the patients was 12 years old and the other, 6 years old. The operation has several advantages. (1) It is very efficient in relieving recurrent gradients. (2) The use of prosthetic material is avoided. (3) Minimal dissection is required. (4) It prevents subsequent subclavian steal syndrome and long-term ischemia of the left upper limb.

The stentless Cryolife-O'Brien aortic porcine xenograft: a five-year follow-up.

BACKGROUND: The 5-year follow-up of CryoLife-O'Brien stentless porcine aortic valve xenografts is presented. METHODS: From August 1991 to August 1996, the valve was used in 366 patients. Patients' ages ranged from 18 to 90 years (mean, 73+/-6 years). Survivors were monitored with Doppler echocardiography before discharge, at 6 months, and then annually by the referring cardiologist. Operative and long-term mortality and morbidity were collected using the Edmunds guidelines for reporting morbidity and mortality after cardiac valvular operations. RESULTS: The study was completed during a 6-month period with a 96.5% follow-up, comprising 999 patient-years for a mean follow-up period of 27 months (range, 3 to 64 months). Operative mortality was 6.5%. Linearized rates per patient-year for complications were as follows: structural valve deterioration (0%); thromboembolism (0.5%); prosthetic valve endocarditis (0.2%); valve reoperation (0.8%); and valve-related mortality (0.2%). Sixteen late deaths have occurred. The actuarial survival rate at 5 years was 83%+/-3.5%. CONCLUSIONS: The Cryolife-O'Brien stentless valve has given excellent early hemodynamic and 5-year results.

Clinical study of normothermic cardiopulmonary bypass in 100 patients with coronary artery disease.

During normothermic cardiopulmonary bypass (CPB), the body temperature is maintained at 37 degrees C. Since 1987, it has been our standard practice to use normothermic CPB in our patients undergoing a cardiac operation, and our experience now consists of more than 3,000 consecutive patients. Myocardial protection is achieved through the combination of cold intermittent antegrade blood cardioplegia, no topical cooling, and a terminal "hot shot" of blood cardioplegia. We disagree with the stance of the Toronto group that normothermic CPB requires the administration of large volumes of cardioplegic and crystalloid solutions and the frequent use of phenylephrine hydrochloride to ensure a low systemic vascular resistance. To establish a routine technique of cold heartwarm body bypass, we conducted a clinical study in 100 consecutive patients with coronary artery disease. We found that the total cardioplegia volume needed in our patients was 1,946 +/- 257 mL, versus 4,700 +/- 1,900 mL in the Toronto study, and an additional crystalloid volume loading of 400 +/- 141 mL during CPB was needed in 26% of our patients, versus a total volume of 3,650 +/- 800 mL in the Toronto series. Phenylephrine (250 micrograms) was used in 16% of our patients, versus 88% of the patients in the Toronto study (mean dose, 1.3 mg). During normothermic CPB, the mean radial arterial pressure was 57.3 +/- 9.4 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful resection of giant intrapericardial lipoma.

We report a case of giant extracavitary cardiac lipoma weighing 4,800 g. The mode of presentation, the preoperative evaluation, and the radiographic features are presented. The surgical management of this very rare cardiac pathology is discussed. This is one of the largest cardiac tumors ever reported.