An in-use microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing.

Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259+/-68 and 244+/-69min for groups S and R respectively (P=0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2h, 4h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2h and 4h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

[Implantation of mechanical pulmonary and tricuspid valve prostheses at a distance from complete repair of Tetralogy of Fallot]. / Implantation de deux prothèses mécaniques, pulmonaire et tricuspide, à distance d'une réparation complète de tétralogie de Fallot.

The authors report the case of a 39 years old woman operated for tetralogy of Fallot at the age of 6. Multiple complications due to postoperative atrioventricular block and a poor surgical result on the pulmonary outflow tract led to several reoperations. Right ventricular dysfunction with pulmonary regurgitation and mitral tricuspid valve disease in a context of endocarditis on the pacing catheter led to double pulmonary and tricuspid valve replacement with mechanical prostheses. The outcome at follow-up at 3 years is good. To the authors' knowledge, this is the first reported case of double mechanical valve replacement of the right heart after complete repair of tetralogy of Fallot.

Modifications of spontaneous cerebral blood flow oscillations during cardiopulmonary bypass.

UNLABELLED: Spontaneous slow waves are present in the systemic circulation including the intracranial compartment. They are supposed to reflect the cerebral autoregulation. We hypothesised that in the absence of cardio respiratory variability, during cardiopulmonary bypass (CPB), we should reveal extreme physiologic controls. MATERIAL/METHODS: Ten patients were included. Arterial blood pressure (ABP, radial invasive), extracorporeal circuitry pressure and cerebral blood flow velocity (CBFV, middle cerebral artery) were recorded. We analysed the slow waves in the B (8 to 50) and the UB (>50 to 200) bands (in milli-Hz). The analysis, before and during CPB, was performed in the tine domain (correlation coefficient, entropy, mean quantity of mutual information, relative entropy) and in the frequency domain (spectrogram, frequency spectrum, coherence). RESULTS: CPB dramatically changed monitored signals decreasing their entropy and revealing a dominant CBFV 70 mHz-frequency and a dominant ABP 9 mHz-frequency. There was no association between the signals (p < 0.05). Before CPB we found complex patterns where B and UB waves were present. CONCLUSION: We hypothesised that CPB provoked a highly protective mechanism, reducing the fluctuations of CBF, by a deactivation of B waves, revealing monotonous UB waves.

Intracardiac ectopic thyroid.

The case of a patient with an intracardiac ectopic thyroid is reported. A lesion was found in a 25-year-old man and was diagnosed by two-dimensional echocardiography as a right intraventricular tumor. An operation was performed. Histologic and ultrastructural studies showed that the tumor was a thyroid mass. The origin of intracardiac ectopic thyroids is probably to be found in disturbances occurring early in embryogenesis.

Systemic-pulmonary shunt with a right retroesophageal subclavian artery.

A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.

Flexible posterior mitral annuloplasty: five-year clinical and Doppler echocardiographic results.

BACKGROUND: Stabilization of the posterior annulus seems to be a critical factor to achieve a stable mitral valve repair. To assess the benefit of softer mural annuloplasty, we analyzed results obtained with the flexible linear reducer. METHODS: From 1985 to 1993, 120 patients, with pure mitral regurgitation, mainly degenerative, had a mitral reconstruction. Mean age was 64+/-11 years and 74% of the patients were in New York Heart Association functional class III or IV. RESULTS: Hospital mortality was 3.3%. Mean follow-up was 56+/-24 months. There were 23 late deaths; 10 valve-related including 7 sudden deaths. Two patients (1.7%) required a reoperation. Doppler echocardiographic studies revealed excellent valve function; 5-year freedom from significant regurgitation was 85.8%+/-5.4%. Mean mitral valve area was 2.76+/-0.77 cm2. Although 105 patients were in class I or II, 23 patients were not functionally improved. Previous myocardial infarction and shorter deceleration time of early filling were risk factors for worsening functional disability. CONCLUSIONS: This support provides stable repair with excellent clinical and echographic results. Previous myocardial infarction and noncompliant left ventricle negatively influence outcome.

Doppler echocardiographic study of three different mechanical valves in the aortic position: the use of external nominal diameter indexed to body surface area.

BACKGROUND AND AIMS OF THE STUDY: Previous studies have demonstrated the benefit of indexing body surface area (BSA) with ventriculo-arterial orifice diameters (or calculated effective surface dynamics) and with nominal external diameters of valves in order to study hemodynamic profiles in vivo or determine the clinical influence of this parameter. This study analyzes the relationship between BSA and nominal external diameter of mechanical valves implanted in the aortic position. It also evaluates the potential interest of using these diameters indexed to BSA in an echo-Doppler study of valves. METHODS: During 1994, a prospective echo-Doppler study of three models of mechanical valves in the aortic position was carried out. RESULTS: The echo-Doppler parameters of the aortic St. Jude Medical, Sorin Bicarbon and Dideco Monostrut prostheses have been studied with regard to nominal external diameters and were found identical to published data. There were no significant differences in these parameters between the three valves. In 128 patients, prosthetic external diameters were evenly distributed heterogeneously with regard to BSA. Indexing of nominal external diameter with BSA appeared a more reliable reference to study different echo-Doppler parameters, minimizing the effect of cardiac output. CONCLUSION: The in vivo echo-Doppler determination at rest of valve hemodynamic profiles should be carried out with reference to the nominal external diameter indexed to the BSA.

Sorin Bicarbon bileaflet valve: a 10-year experience.

OBJECTIVE: To present a large 10 year experience of a collaborative evaluation of the Sorin Bicarbon (SB) mechanical prosthesis carried out in 14 centers in eight Western European countries. METHODS: Between 4/90 and 12/96, 2078 SB valves were implanted in 1875 patients aged 4-84 years (mean 58), 1108 males and 767 females. The valves inserted were 1026 aortic valve replacement (AVR), 656 mitral valve replacement (MVR) and 203 double valve replacement (DVR), additional procedures performed in 467 patients (282 coronary artery bypass grafting). RESULTS: Early mortality was 97 (5%), overall survival at 8 years was 71.8% AVR, 69.4% MVR, 81.4% DVR. Total late valve-related deaths were 55; overall freedom from valve-related death at 8 years was 95%. New York Heart Association (NYHA) status after surgery: 78% improved and 17% unchanged. Twenty-two valve thrombosis were observed, one fatal; overall freedom from thrombosis at 8 years was 98.5%. Embolism occurred in 95 patients, 77 cerebral events (16 deaths), overall freedom from embolism was 90.7% at 8 years. Six hemolytic events and 26 non-structural dysfunction (all periprosthetic leaks) were reported. Major bleeding occurred in 66, with mortality rate of 32% mainly when intracerebral. Overall freedom from bleeding was 90.8% at 8 years. Endocarditis occurred in 31 patients, 29% were fatal; overall freedom from endocarditis was 97.8% at 8 years. Reoperation was performed in 49 cases--periprosthetic leak 20, infective endocarditis 14, thrombosed valve 13 (and non-valve related-2). Mortality (early and late) occurred in three reoperated patients. CONCLUSIONS: This is a durable and effective mechanical valve substitute with low morbidity and mortality and good functional results.

Coil embolization of a false aneurysm with aorto-cutaneous fistula after prosthetic graft replacement of the ascending aorta.

AIM: To report palliative embolization of a false aneurysm over the distal suture line of an ascending aorta graft replacement. MATERIAL AND METHOD: A 78-year-old male patient was admitted for increasing bleeding of a chronic Manubrium ulceration, 20 months after coronary artery bypass complicated by perioperative ascending aorta dissection requiring prosthetic graft replacement. One month later, he underwent epiploplasty for a mediastinitis followed by long-term antibiotic therapy. Five months later, he presented with a Manubrium ulceration of the sternotomy. Spiral computerized tomography (CT) and aortography revealed a 20 mm anterior peri-prosthetic false aneurysm with a wide neck. Advanced age, active mediastinitis and patient's objection led us to perform percutaneous occlusion according to the Moret remodeling technique while protecting the coils release with balloon catheter inflation. RESULTS: No post-operative complication was observed and at 1-year follow-up the patient was doing well with no recurrent bleeding. Magnetic resonance imaging (MRI) and spiral CT controls confirmed coils stability without any internal flow. CONCLUSION: Percutaneous coils embolization of a large false aneurysm in the ascending aorta can be a palliative treatment in a surgically unsuited patient.

[Association of cor triatriatum and obstruction of abnormal left pulmonary venous drainage. Apropos of a case]. / Association d'un coeur triatrial à une obstruction au retour veineux pulmonaire anormal gauche. A propos d'une observation.

A case of subtotal cor triatriatum associated with a partial anomalous pulmonary venous drainage of the left lung, in a 30 months old boy is reported. Diagnosis was suggested by the presence of pulmonary venous obstruction and pulmonary hypertension. Doppler, echocardiogram diagnosed the cor triatriatum and the degree of the pulmonary hypertension. The cine-angiography demonstrated the anomalous, obstructive, left pulmonary venous drainage. The pulmonary hypertension has mandatorised an early surgical cure, the result was satisfactory at 16 months.

[Interruption of the left aortic arch with right descending thoracic aorta disclosed in adulthood]. / Interruption d'un arc aortique gauche avec aorte thoracique descendante droite découverte à l'âge adulte.

Evaluation of hypertension, in a 30 years old man, revealed an interruption of a left aortic arch beyond the origin of the left subclavian artery, associated with a right descending thoracic artery. Surgical restoration of the continuity between the ascending aorta and the low descending aorta was successfully achieved by interposition of a graft. Survival in adulthood without bronchial compression, is explained by the absence of ventricular septal defect and patent ductus arteriosus.

[Double aortic and mitral valve replacement in an 18 year old patient with Hunter's disease]. / Double remplacement valvulaire aortique et mitral chez un patient de 18 ans atteint d'une maladie de Hunter.

Hunter's disease, a type II mucoplysaccharidosis, a disease of lysosomal overload, may cause cardiovascular disease. This mainly affects the valves of the left heart which are infiltrated, and results in regurgitation rather than stenosis of the aortic and mitral valves. The general context of this disease explains the fact that only one case of mitral valve replacement was found in a review of the literature. The authors report the case of a young patient who was very symptomatic because of mitral and aortic regurgitation and who underwent double valve replacement of the aortic and mitral valves with mechanical prostheses at 18 years of age. The skeletal involvement and respiratory function led to much discussion before surgical referral but the indication was finally retained in view of the patient's practically normal intellectual functions. Seven years later, the patient is asymptomatic from the cardiac point of view and has been included in a protocol of enzyme therapy.

[Pulmonary stenosis with tricuspid insufficiency in the child]. / Sténose pulmonaire avec insuffisance tricuspidienne chez l'enfant

The authors report 3 cases of pulmonary stenosis with an intact interventricular septum and tricuspid incompetence. The tricuspid regurgitation was corrected in all 3 cases. After recalling the clinical features, they emphasize the importance of seeking for this condition and correcting it in every case if the immediate and long-term results are to be satisfactory.

[Assisted circulation by external heterotopic prosthesis as a bridge to heart transplantation]. / Assistance circulatoire en attente de transplantation cardiaque par prothèse hétérotopique externe.

Eleven patients aged 7 to 58 years were placed on assisted circulation with Pierce (2 cases) or Abiomed (9 cases) external prosthetic ventricles as a bridge to cardiac transplantation. The indications were terminal cardiac failure following cardiomyopathy (7 cases), decompensated ischemic heart disease (3 cases) and subacute post-transplantation rejection (1 case). The duration of the assisted circulation ranged from 24 hours to 11 days. All patients were transplanted but 3 died after transplantation (27%). The circulatory assistance was satisfactory in all patients as shown by the regression of clinical signs of low cardiac output and the normalisation of diuresis. The complications observed during assisted circulation and after cardiac transplantation were: haemorrhage (36%), infection (27%) and thromboembolism (9%). These preliminary results with a 72% post-transplantation survival rate, show that both systems are effective "bridges to cardiac transplantation". The Abiomen device is excellent value for money and relatively simple to install and represents a good compromise between the sophisticated techniques of circulatory assistance and the problems of the cost of health care.

[Brucella endocarditis caused by reinfection of an aortic Starr valve. Apropos of a case with a favorable development after valvular replacement]. / Endocardite brucellienne par réinfestation sur valve de Starr aortique. A propos d'un cas d'évolution favorable après remplacement valvulaire.

We report the case of a 36-year old male patient who was admitted for subacute endocarditis on an aortic prosthetic valve implanted 14 years previously for endocarditic valve regurgitation; no pathogen had been isolated at that time. Nine blood cultures were positive for Brucella abortus. The conventional antibiotic therapy did not prevent the formation of an abscess below the aortic annulus. A third antibiotic combination (quinolone and rifampicin) resulted in pyrexia prior to surgery. An atrioventricular block initially noted raised the problem of an associated myocarditis. The risk of Brucella infection existed before the first operation, and five serological tests were positive for that organism between the two episodes, which makes reinfection highly probable. This is the third case of Brucella endocarditis on a prosthetic valve. Its originality lies in its mechanism.

[Antenatal cardiac surgery. Creation of an experimental model of pulmonary stenosis in the fetus and repair in utero]. / Chirurgie cardiaque anténatale. Réalisation d'un modèle expérimental de sténose pulmonaire chez le foetus et réparation in utero.

An experimental model of pulmonary stenosis was created in ewes, fetus and repaired before birth by making use of the materno-foetal circulation. Eighteen ewes fetus underwent pulmonary artery banding at an average of 87 +/- 8 days' gestation (normal 135-145 days). All were reoperated before term at 132 +/- 6 days' gestation. They were divided into two groups : group I (7 fetus) was used to evaluate the experimental model of pulmonary stenosis by measuring right ventricular pressures (80 +/- 16 mmHg compared to 58 +/- 10 mmHg in control models), and the increase in right ventricular mass (2.8 +/- 0.5 X 10(-3) g vs 1.9 +/- 0.2 X 10(-3) g), left ventricular mass (2.2 +/- 0.3 X 10(-3) g vs 1.8 +/- 0.4 X 10(-3) g) and septal mass (1.8 +/- 0.3 X 10(-3) g vs 1.3 +/- 0.2 X 10(-3) g). In group II (11 fetus) the pulmonary stenosis was repaired by total clamping and patch repair. After repair and during the days just before birth, the ventricular masses decreased (RV = 2 +/- 0.3 X 10(-3) g; LV = 1.8 +/- 0.4 X 10(-3) g; septum = 1.8 +/- 0.3 X 10(-3) g) approaching values of normal control fetus. This experimental model shows that it is possible to correct cardiac lesions in utero by making use of the materno-fetal circulation and that antenatal repair of an arterial obstruction can rapidly reverse the reactional ventricular hypertrophy.

[Medullary extradural hematoma revealing a coarctation of the aorta]. / Hématome extra-dural médullaire révélant une coarctation de l'aorte.

The authors report a spontaneous, unusual complication of coarctation of the aorta. An 11 year old child was admitted for investigation of chest pain. Cardiovascular examination revealed typical clinical signs of coarctation of the aorta. Neurological examination found neck stiffness without headache or deficit. The presumptive diagnosis of dissection of the aorta was infirmed by echocardiography and MRI. The latter investigation, with views of the spinal cord, revealed a compressive medullary extradural haematoma. Antihypertensive therapy and corticosteroids with strict bed rest resulted in complete regression of the haematoma and the coarctation was operated 6 months later. Medullary complications of coarctation of the aorta are usually postoperative. Spontaneous complications are exceedingly rare but very serious: medullary compression by the dilated anterior spinal artery or rupture of an aneurysmal collateral vessel. In this case, magnetic resonance imaging led to diagnosis and effective early treatment of this complication before the patient developed a neurological deficit and the coarctation was treated surgically thereafter.

[Hancock pericardial prosthesis. Intrinsic dysfunctions]. / Prothèses de Hancock péricardiques. Dysfonctions intrinsèques.

The frequency of primary dysfunction of 432 Hancock pericardial bioprosthesis was evaluated during a mean follow-up period of 53.1 months per patient. This frequency was 3.20% valve-year in mitral valve prosthesis and 0.92% valve-year in aortic valve prosthesis. Only one case of calcification was noted. Dysfunction was usually due to tearing of one or several pericardial cusps (25 cases), occasionally to tissue retraction (4 cases). Pathological examination of the explanted valves showed fibrin formation followed by organization into fibrous tissue in the host, retracting or fragilizing the pericardial valvular tissue. A preliminary study of the same group had led to discontinuation of Hancock prosthesis. The long follow-up period makes it possible to compare the results obtained with those of pericardial prosthesis of the same generation, to stress the need for echocardiographic monitoring of the implanted valves and to hope that new techniques of pericardial valve fitting will improve the mechanical reliability of prosthesis which, from the point of view of thrombogenesis and haemodynamics, have unquestionable advantages.

[Congenital pulmonary arteriovenous fistula. Apropos of 2 cases]. / Fistule artério-veineuse pulmonaire congénitale. A propos de deux observations.

The authors discuss echocardiographic diagnosis and endovascular treatment of two different anatomical types of pulmonary arteriovenous fistula. Transoesophageal echocardiography in a cyanotic 3 year old boy revealed a direct right pulmonary artery left atrial fistula, treated by surgical ligation of the anomalous feeding artery. A cerebral abscess in a 22 year old man with hereditary haemorrhagic telangiectasia revealed pulmonary and cerebral arteriovenous malformations, which were both treated successfully by embolization. The value of echography is the demonstration of the right to left shunt at pulmonary level and, in some cases, the direct visualization of the arteriovenous malformation. Embolization should be considered as the therapeutic method of choice in all pulmonary arteriovenous fistula, except for direct pulmonary artery left atrial fistula.

[Identification of hibernating myocardium using 99m sestamibi tomoscintigraphy at rest]. / Identification du myocarde hibernant par la tomoscintigraphie de repos au technétium 99m sestamibi.

The aim of this study was to assess the value of resting 99m Tc-Sestamibi scintigraphy for the detection of hibernating myocardium in zones of contractile dysfunction. Based on a series of 25 patients, 27 segments of supposedly hibernating myocardium were identified. All these segments corresponded to left ventricular wall motion abnormalities confirmed by contrast angiography and were perfused by a stenosed coronary artery: none of these zones were infarcted. Before revascularisation, comparison of the results of ventriculography and scintigraphy showed a correlation (p < 0.001) between the severity of regional contractile dysfunction appreciated by the center line method and the degree of myocardial hypofixation of 99m Tc MIBI. Three months after revascularisation, improvement of regional wall motion, assessed by control contrast angiography, was observed in 21 of the 27 segments studied (78%). Of these 21 segments, the viability of which was confirmed, 13 had a non-transmural uptake defect and 8 were normal on pre-revascularisation scintigraphy. The 6 segments without improvement at the 3 month control, had a transmural uptake defect on scintigraphy in 67% of cases. The authors concluded that when a residual uptake defect of 99m Tc sestamibi is present, viable myocardium may also be present.