Effects of two different crystalloid cardioplegic solutions assessed by myocardial pH, tissue lactate content and energy metabolism.

OBJECTIVE: The influence of composition of crystalloid cardioplegia is imprecise in clinical practice. Therefore, we investigated changes in intramyocardial pH, tissue lactate content and energy metabolism during cardioplegic arrest with 2 different crystalloid cardioplegic solutions. METHODS: Twenty patients were randomly allocated to 2 groups: 10 patients had crystalloid cardioplegia buffered with bicarbonate (neutral pH of 7.8 at 20 degrees) with no additives (St Thomas' II solution) and 10 patients had a non buffered crystalloid cardioplegia (mildly acidic pH of 7.4 at 20 degrees) enriched with glutamate and mannitol (Menasché's solution). Tissue lactate and energy metabolism were measured on myocardial biopsy specimens and intramyocardial pH were continuously measured during cardioplegic arrest by a miniature glass electrode. RESULTS: There were no statistical differences in hemodynamic results and in AMP, ADP, ATP, lactate values measured on biopsy specimens. The curves of intramyocardial pH were very similar in the 2 groups, the median values were 7.42 +/- 0.1 in group 1 and 7.41 +/- 0.1 in group 2 (temperature corrected values) and the areas under the curves were 260 +/- 4 and 259 +/- 4 in groups 1 and 2 respectively (P = NS). CONCLUSIONS: Glutamate provided no additive metabolic myocardial protection, bicarbonate had a weak buffering capacity in cold cardioplegic solutions and the 2 studied crystalloid solutions warranted a good myocardial protection in clinical practice.

Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients.

OBJECTIVE: To test the hypothesis that the skeletonized technique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. METHODS: Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6 +/- 0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9 +/- 8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. RESULTS: Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 +/- 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. CONCLUSION: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.

[Atypical coarctation of the thoracic aorta caused by fibromuscular dysplasia]. / Coarctation atypique de l'aorte thoracique par dysplasie fibromusculaire.

Fibromuscular dysplasia is a non-inflammatory disease unrelated to atherosclerosis of the small and medium sized arterial walls, which often affects the renal and carotid arteries and occurs mainly in women. The authors report a case of atypical coarctation of the thoracic aorta due to fibromuscular dysplasia confirmed histologically in a 27 year old man. Arteriography was performed because of hypertension and asymmetry of blood pressure measurements and showed irregular stenosis of the aortic isthmus and of the origin of the left subclavian artery. Surgery comprised resection of the pathological segment of the aorta which was replaced by a prosthetic tube with reimplantation of the left subclavian artery. Histological examination showed fibromuscular dysplasia in perimedial areas and diffusely throughout the media. To the author's knowledge this is the first case to be reported in the medical literature.

[Value and indication of the use of 2 internal mammary arteries in repeated coronary surgery]. / Intérêt et indication de l'utilisation des 2 artères mammaires internes dans la chirurgie coronaire redux.

Forty-nine patients who had coronary artery reoperations were divided into two groups: the 29 patients of the first group were operated conventionally with use of one internal mammary artery or a saphenous vein; the 20 patients of the second group were reoperated using both internal mammary arteries. Three patients (6%) died prematurely: two in the first and one in the second group. The rates of peri-operative infarction were 7% and 15% respectively. The average postoperative bleeding was 472 +/- 385 ml in the first group and 700 +/- 628 ml in the second group (NS). All patients are pauci-symptomatic and have a negative exercise stress test. The mortality and morbidity of coronary reoperation does not seem to be greater with double internal mammary artery bypass grafting. However, this technique should be reserved for patients who can derive long-term benefit from reoperation with arterial grafts, that is to say in patients in good clinical condition, less than 65 years of age with good left ventricular function. In these patients, double internal mammary artery bypass grafting may avoid a third operation for myocardial revascularisation.

[Coronary artery bypass with 2 internal mammary arteries. Early clinical and angiographic results in 100 patients]. / Pontages coronaries avec les 2 artères mammaires internes. Résultats cliniques et angiographiques précoces chez 100 malades.

One hundred patients underwent coronary revascularisation with both internal mammary arteries between 1987 and 1990. The average age of the patients was 55 years. The left internal mammary was used in 97 of the 100 cases as a pediculated graft to revascularise the left anterior descending (66 cases), left lateral (27 cases) or a bissecting artery (4 cases). The right internal mammary was used as a pediculated graft in 51 cases and as a free graft to revascularise a left lateral (51 cases), left anterior descending (29 cases) or right coronary artery (20 cases). There was one death in the first 30 postoperative days. Morbidity was low with no cases of sternal infection. The average postoperative bleeding was 633 +/- 550 ml per patient. The incidence of phrenic nerve paralysis decreased from 36% in the first 50 patients to 6% in the second 50 patients. Angiography at the 10th postoperative day showed 4 occlusions out of 132 internal mammary arteries opacified (97% patency). Ninety four patients are asymptomatic and have negative exercise stress tests. Mortality and morbidity of coronary surgery using the two internal mammary arteries are therefore the same as those of conventional coronary surgery using saphenous veinar only one internal mammary artery, providing that it is reserved for patients in good general condition, under 65 years of age, without obesity or diabetes. This technique of coronary artery revascularization should provide better long-term results because of the high patency rate of the grafts.

[Decrease of postoperative morbidity in coronary surgery using the two internal mammary arteries]. / Diminution de la morbidité post-opératoire dans la chirurgie coronaire utilisant les deux artères mammaires internes.

The surgical risk of bilateral internal mammary artery grafting was analyzed in 100 successive patients separated chronologically into two groups. These groups were not statistically different in terms of age, severity of angina, and extent of coronary artery disease. The number of grafts per patient and the time of aortic cross clamping were not statistically different in the two groups. The postoperative mortality was 1% in the 100 patients. The incidence of perioperative myocardial infarction was not statistically different in the two groups. No mediastinal suppuration was observed. The mean postoperative hemorrhage was 633 +/- 558 ml in the first 50 patients and 560 +/- 410 ml for the last 50 patients (p < 0.05). The percentage of patients receiving no homologous blood transfusion was 64% in the first 50 patients and 94% in the last 50 patients. The percentage of phrenic palsy was 36% in the first 50 patients and 6% in the last 50 patients (p < 0.05). With surgical experience, the risk of coronary bypass with bilateral internal mammary artery was lowered and very similar to the surgical risk of conventional aorto-coronary bypass with saphenous veins or one mammary artery.

Comparison of different types of cardioplegia and reperfusion on myocardial metabolism and free radical activity.

Current techniques of myocardial protection during global ischemia include hypothermia, cardioplegic arrest and controlled reperfusion. To compare different types of cardioplegia and reperfusion techniques we measured the levels of adenine nucleotides and malondialdehyde (MDA, as free radical activity) in 33 patients undergoing heart surgery. The patients were randomized in three groups according to the characteristics of cardioplegia and reperfusion: cold blood cardioplegia with unmodified blood reperfusion (control group, 11 patients), crystalloid cardioplegia and reperfusion (Hôpital Lariboisière protocol, 11 patients) and crystalloid cardioplegia with allopurinol enriched blood reperfusion (Hôpital Broussais protocol, 11 patients). Myocardial biopsy specimens were obtained before cardioplegic arrest (preischemic values), at the end of ischemia and after 30 minutes of reperfusion. Biopsy specimens were analyzed by high performance liquid chromatography for levels of adenine nucleotides and MDA. In the three groups, the preischemic values of adenine nucleotides and MDA were not significantly different. For AMP and ADP concentrations neither treatment nor biopsy-time effects appeared. ATP concentration decreased significantly with biopsy-time without specific treatment effect. For MDA concentration neither treatment nor biopsy-time effects were observed. This study suggests that there is no statistically significant difference between any of the three cardioplegia and reperfusion techniques for either ATP or MDA; the three reperfusion techniques limit the free radical activity but do not prevent the fall in high energy phosphates.

[Value of coronary reperfusion in cases of very low cardiac output following coronary artery bypass grafts]. / Intérêt de la reperfusion coronaire dans les bas débits cardiaques graves après pontage coronaire.

From January 1986 to December 1988, 244 patients had a coronary artery revascularization at St Joseph Hospital. Four patients (1.8%) died in post operative time (less than 30 days). None died directly from cardiogenic shock. Five patients had a severe low cardiac output (2 h to 48 h post-op) and needed cardiac resuscitation. These patients were immediately taken to the operating room. The coronary bypasses were explored (2 technical errors corrected), the metabolic disorders were treated and a coronary reperfusion was done with the Buckberg's technique. All the patients could be weaned from cardiopulmonary bypass, two with intra aortic balloon pumping. One patient died of digestive complication the 10th postoperative day. The four other patients survived and are in good clinical condition. The severe low cardiac output after coronary revascularization can be reversible with resuscitation in operating room, short assistance, and coronary reperfusion.

[Evaluation of 90 normal aortic valve prosthesis of the Saint-Jude Medical type by echocardiography]. / Evaluation par échocardiographie doppler de 90 prothèses valvulaires aortiques normales de type Saint-Jude Medical.

Between September 1986 and February 1989, ninety patients undergoing isolated aortic valve replacement were studied on the 15th postoperative day, in the Department of Cardiac Surgery at St Joseph's Hospital, Paris. Patients with a diastolic murmur, fever, significant, pericordial effusions and poor quality Doppler recordings were excluded. The aim of the study was to determine normal Doppler echocardiographic parameters of St Jude medical aortic valve prostheses. Maximum and mean transprosthetic pressure gradients were calculated by the simplified Bernoulli equation. Functional value surface area was assessed by the continuity equation using the diameter of the left ventricular output tract measured by 2D echocardiography (continuity) and the external diameter of the prostheses (modified surface area) to calculate the subaortic surface area. The transprosthetic pressure gradients G max and G mean were inversely correlated to the size of the prostheses (r = 0.42 and r = 0.45). The functional valve surface area calculated by the continuity method gave a poor correlation but this improved considerably when the diameter of the prosthesis (modified surface area) was considered. Finally, the permeability index which is the ratio of subaortic and transaortic velocities seemed to be a good parameter for assessing prosthetic valve function.

[Peroperative autologous transfusion in cardiac surgery. Course, medical and economic evaluation. Prospects]. / Transfusion autologue per-opératoire en chirurgie cardiaque. Evolution, bilan médical et économique. Perspectives.

The authors report their experience since 1979 in the utilization of a system for blood salvaging in cardiac surgery. An initial comparative study showed that the patient group in which blood salvaging was used, received only 0.8 unit of red cells per patient and per hospitalisation and 50% of patients required no transfusion. In the patients receiving ATS, postoperative bleeding was significantly decreased. To confirm the advantages of the technique, a group of 200 patients was studied, consisting of 28 children and 172 adults. Hemodilution was difficult to perform in children weighing less than 15 kg. Nevertheless, ATS allowed for a significant reduction in the number of red cell units transfused. In the adult group, homologous blood consumption was 0.3 unit per patient and per hospitalization. 83% of the patients received no red cells, and 93% had no need for FFP. This reduction in homologous blood transfusion ensures a reduction in the transfusional risk. An improvement in these results will be obtained by a better organization of preoperative ATS and of the retrieval of postoperative blood.

Cardiac pacing and valvular surgery.

Over a 17-year period (1970-1987) 75 patients, 3% of overall valvular surgery (VS) patients have been permanently paced at the time of VS (group 1), nine have been paced long after (group 2), 12 were already paced at the time of valve replacement (group 3), and 81 had a permanent pacing lead inserted during VS without further need for permanent pacing (group 4). Based on pre-, per- and post-operative clinical and electrocardiographic data we studied these four groups (GR). Aortic disease and especially calcified aortic stenosis (CAS) are the main valvular pathologies in all GR. The survival rate in GR 1 is lower than the survival rate of our overall VS PT5 due to older average ages and more severe cardiac conditions. In five patients GR 2 a myocardial pacing lead placed during VS was used long after for permanent stimulation. Patients in GR 3 were older than in other GR at the time of VS. The mortality was high in the patients operated on between 1973 and 1978 (average survived 3.5 years after pacing/2 years after VS) thus demonstrating the benefit of myocardial protection. For GR 4 the ratio of permanent lead implantation during VS was high in the late seventies (10%), it is now around 0.5%. In cases where the evolution of peroperative conduction disturbances is doubtful, it seems to us simpler to place a myocardial lead avoiding subsequent endocardial pacing if necessary, later, especially in patients with tricuspid disease.

[Cor triatriatum of adults. Apropos of 2 new surgically treated cases in adults]. / Coeur triatrial de l'adulte. A propos de 2 nouveaux cas opérés chez l'adulte.

The authors report two cases of cor triatriatum in a 54 year old woman undergoing open heart surgery with a preoperative diagnosis of mitral stenosis, and a 24 year old woman in whom the diagnosis had been made before surgery. Resection of the abnormal intra-left atrial fibrous membrane successfully restored normal haemodynamics in both cases. The main clinical and diagnostic features of the condition are described.

[Surgical treatment of pulmonary metastases. Apropos of 26 cases]. / Traitement chirurgical des métastases pulmonaires. A propos de vingt-six cas.

Twenty-six patients with known primary tumors were treated surgically for pulmonary metastases between 1951 and 1979. The metastases were diagnosed more often (58% of cases) by routine radiological examinations than because of thoracic symptoms. While diagnosis of the primary tumor and the metastases was simultaneous in three cases, the average lapse of time between the two diagnoses was 5 years and 1 month in the other cases. In four cases, it was 10 years or more. Lung X-rays showed single tumors more often than multiple tumors (12%). Broncho-fibroscopy was usually normal, but a preoperative biopsy showed the metastatic nature of the tumor in 5 cases. Ablation was by lobectomy (42%), pneumonectomy (23%) or atypical resection (27%). The hospital mortality rate was 7.6%. The survival rate at 1, 3 and 5 years (71%, 39%, and 17%) is identical to that of primitive bronchial tumors, and seems to be influenced by certain factors, such as the locus of the primitive tumor (with a particularly bad prognosis for ENT tumors), the lapse of time between the diagnoses of the primary and secondary tumors, the fact that there is one, rather than several, metastases, or that the metastases are monolateral rather than bilateral, and, finally, the limited nature of the exeresis. These factors prompt regular, systematic and prolonged radiological monitoring in search of further pulmonary metastases.

[Metastatic pulmonary echinococcosis secondary to a primary cardiac lesion situated in the interventricular septum. One case successfully treated surgically (author's transl)]. / Echinococcose pulmonaire métastatique, secondaire à une localisation cardiaque primitive située dans le septum interventriculaire. A propos d'un cas opéré avec succès.

The authors report a case of metastatic pulmonary echinococcosis secondary to a primary cardiac lesion. The diagnosis was made on the basis of round pulmonary lesions developing during an episode of cardiac diseases which had been labelled as idiopathic acute pericarditis. The septal site then suspected on the basis of minor conduction disturbances was confirmed by angiography and could be excised under extracorporeal circulation.

[Comparative study of mechanical and manual suture of bronchial stumps in pneumonectomy (author's transl)]. / Suture mécanique et manuelle des moignons bronchiques dans la pneumonectomie. Etude comparative.

The incidence and time of onset of bronchial fistulae were retrospectively studied in 306 patients who underwent pneumonectomy at the Saint-Joseph Hospital, Paris, between 1975 and 1979. The bronchial suture was performed mechanically in 145 cases and manually in 161 cases. Patients in both groups were of comparable age, lung disease, side operated upon, nature of the bronchial division, post-operative course and surgeon's ability. From the results of the study, the authors have endeavoured to determine the advantages of mechanical suture as opposed to manual suture with regard to both operatory technique and quality of results.

Left atrial myxoma in the elderly: diagnosis by M-mode and bidimensional echocardiography.

Two cases are reported of left atrial myxoma in elderly patients, diagnosed by combined M-mode and bidimensional echocardiography. One patient was an 80-year-old man presenting with typical signs of mitral obstruction by an atrial tumor. His symptoms were erroneously attributed to chronic bronchitis until an echocardiogram was obtained. The other patient was a 70-year-old woman with atrial fibrillation of one year's duration. Left atrial myxoma, although rarely observed in the elderly, may be diagnosed easily by means of echocardiography. Some cases may prove amenable to surgical treatment.

Surgical treatment for a complicated congenital aortic stenosis. The association of a three-level obstruction of the left ventricular outflow tract with mitral incompetence, coarctation of the aorta, and the Wolff-Parkinson-White syndrome.

We report a case of complex congenital aortic stenosis with obstruction at all three levels of the left ventricular outflow tract (subaortic, aortic, and supravalvular aortic stenoses) associated with a mitral malformation, coarctation of the aorta, and the Wolff-Parkinson-White syndrome. The subaortic stenosis was corrected by excision and myotomy, and the supravalvular stenosis by a widening prosthetic operation with a Dacron patch extending as far as the aortic ring, at which level a Björk-Shiley No. 17 aortic prosthesis was inserted. The mitral valve was replaced by a Lillehei-Kaster prosthesis. The coarctation of the aorta was not significant and was left alone. Permanent pacing was needed because of peroperative surgical section of the bundle of His. Reviews of the literature and the various techniques used to widen the left ventricular outflow tract are included.