Increased cerebral blood flow velocities assessed by transcranial Doppler examination is associated with complement activation after cardiopulmonary bypass.

The role of complement activation on the cerebral vasculature after cardiopulmonary bypass (CPB) is unclear. The goal of the study was to assess whether heparin-coated CPB reduces complement activation, and influences cerebral blood flow velocities (CBFV). Twenty-four patients undergoing coronary surgery were randomly allocated to non-coated (NC-group) or heparin-coated (HC-group) CPB. Complement activation was assessed by measuring sC5b-9. Transcranial Doppler (TCD) was performed on middle cerebral arteries before and after CPB. Systolic (SV), diastolic (DV) and mean (MV) CBFV were measured. Significant increase of sC5b-9 (p=0.003) was observed in the NC-group and CBFV increased after CPB (SV by 27%, p=0.05; DV by 40%, p=0.06; MV by 33%, p=0.04) whereas no changes were detected in the HC-group. TCD values were higher in the NC-group than in the HC-group (SV, p=0.04; DV, p=0.03; MV, p=0.03) although cardiac index, systemic vascular resistance, haematocrit and pCO(2) were similar. Postoperative SV, DV and MV were significantly correlated with sC5b-9 (r=0.583, p=0.009; r=0.581, p=0.009; r=0.598, p=0.007, respectively). Increased CBFV after CPB are correlated to the level of complement activation and may be controlled by heparin-coated circuits.

Tricuspid atresia. Results of treatment in 115 children.

We present our experience in the management of tricuspid atresia in 115 children. The anatomic data are categorized as follows: type I, 83.5%, type II, 16.5%. Type IB is the most frequent, representing 63.5% of all the cases. Each patient was operated upon one to four times. The age at first operation ranged from 10 days to 20 years. The first operation was a shunt in 94 children, a Fontan operation in four, and banding of the pulmonary artery in 17. Hospital mortality for the first operation was 12.2%, significantly higher in children under 6 months and in those having Waterston shunts. Potts and Blalock-Taussig operations give low long-term mortality; although few (six) have been done, Potts shunts also seem to give good long-term palliation in this series. The Glenn anastomosis is a good operation when performed after a systemic-pulmonary arterial shunt. The Fontan operation was performed in 24 children (hospital mortality 16.6%). There have been no late deaths after the third month postoperatively. Mean follow-up for this operation is only 2 years, but 88% of the survivors lead a normal life, two thirds of them receiving no treatment. There has been one reoperation for stenosis of a Dacron conduit with a good result. Late arrhythmias are well tolerated. In conclusion, the Fontan procedure is a good operation, but palliative procedures still allow good long-term survival.

Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain.

BACKGROUND: Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the brain, especially when the internal jugular vein is valvulated (88% of the cases). This anatomic study was carried out to determine how a liquid injected in the superior vena cava reaches the brain. METHODS: Three groups of adult cadavers (5, 5, and 3 cases, respectively) were injected with latex, colored blue, through a cannula in the superior vena cava. In group I, 600 mL of latex was injected. Group II was identical except that a catheter had been inserted, before the injection, into the internal jugular vein to collapse the internal jugular vein valve, when existing. In group III, the azygos vein was ligated. RESULTS: The internal jugular vein was not valvulated in 2 cases in group I. In those 2 cases, latex was found up to the jugular foramen. In the other cases in group I, and in all cases in group II, where the internal jugular vein was valvulated, the following veins were injected: internal jugular vein up to the valve (almost no latex beyond), azygos vein, inferior vena cava, renal veins, rachidian and perimedullar venous plexuses, and venous sinuses of the brain. In group III, no opacification was observed beyond ligated azygos vein or valvulated internal jugular vein. CONCLUSIONS: Despite the fact that this study was carried out on cadavers, one can assume that, during retrograde cerebral perfusion, the azygos vein system is a major way to the central nervous system when the internal jugular vein is valvulated.

Doppler-echocardiographic assessment of the carbomedics supra-annular 'Top-Hat' prosthetic heart valve in the aortic position.

Twenty-one CarboMedics 'Top-Hat' bileaflet prostheses were implanted in the aortic position between May 1993 and May 1994 at our institution. Valve performance was assessed by repeat echocardiography. We found it very easy to implant this prosthesis even in the small aortic annulus and it allowed us to implant a valve that is at least one size larger than implantation in the intra-annular position allows. The only contraindication to the implantation of this prosthesis is when the coronary ostia are displaced downwards, which would apply to any supra-annular prosthesis. The Doppler echocardiographic assessment showed acceptable transvalvular gradients and velocity indexes. The Top-Hat prosthesis is now our valve of choice in the small aortic annulus.

The CarboMedics 'Top-Hat' aortic valve prosthesis: short-term results.

BACKGROUND AND AIM OF THE STUDY: The CarboMedics 'Top-Hat' aortic valve prosthesis has been specifically designed for supra-annular implantation. The aim of this study was to assess the safety of implantation of this prosthesis by reporting the short-term results of follow up. METHODS: Between May 1993 and May 1998, 128 patients (mean age 62.5 +/- 9.8 years; range: 22-76 years) received a CarboMedics 'Top-Hat' prosthesis at our institution. Among patients, 55% were in NYHA functional classes III or IV, and 54.7% had an isolated aortic valve replacement. Associated procedures were: coronary artery bypass grafting (25.7%), double valve replacement (17.1%), treatment of ascending aortic aneurysm (4.7%) and miscellaneous (5.5%). Follow up was 100% complete; total cumulative follow up was 265 patient-years (pt-yr) (range: 2-60 months). RESULTS: The overall mortality rate was 1.5% (two deaths). The operative mortality rate was 0.8% (one death); this patient died from neurological complications after operation for aortic dissection. The other patient died on postoperative day 40 from a massive cerebral hemorrhage. Four patients presented thromboembolic events; in all cases these were reversible ischemic neurologic deficits. One patient had a nonstructural deterioration (endocarditis) and required reoperation. Freedom from mortality was 98.3% at five years (linearized rate of 0.75%/pt-yr). Freedom from thromboembolism was 63.1% at five years (linearized rate 1.5%/pt-yr). CONCLUSION: Short-term results with the CarboMedics 'Top-Hat' prosthesis were satisfactory, with low rates of morbidity and mortality. As this prosthesis has demonstrated a good reliability to date, we have continued its implantation in our institution, and long-term follow up will be necessary to confirm these good early results.

[Contribution of magnetic resonance imaging to the diagnosis of aortic coarctations]. / Apport de l'imagerie par résonance magnétique au diagnostic des coarctations de l'aorte.

The authors present a case of coarctation of the aorta in a 28-year old male patient explored by magnetic resonance imaging. The exploration was carried out with an 0.5 Tesla magnet machine, using 2-echo spin-echo sequences synchronized with electrocardiography. Contiguous axial, frontal and oblique 10 mm thick sections were performed. In this particular case the images were of much better quality than with other exploratory methods, notably digital angiography. Not only the coarctation, but also two large aneurysms of the intercostal arteries were visualized. It is important to obtain this kind of information prior to surgery in view of the higher risk of haemorrhage. Magnetic resonance imaging could already be used as first-line exploration in some cases of congenital vascular pathology. However, its use is for the moment limited, in particular by the fact that it does not provide information on cardiac valve functioning.

[Magnetic resonance imaging in the evaluation of the postoperative results in tetralogy of Fallot. Apropos of a case]. / Evaluation en imagerie par résonance magnétique du résultat post-opératoire dans la tétralogie de Fallot. A propos d'un cas.

The magnetic resonance images obtained post-operatively in a case of Fallot's tetralogy are presented. These images provide perfect visualization of the intracardiac structures, notably those which make it possible to evaluate the results of surgery, namely the patency of the pulmonary out flow tract. Magnetic resonance imaging (MRI) is still of limited use, but this examination will no doubt be more frequently performed when forthcoming techniques enabling gradients and blood flows to be evaluated and dynamic images to be obtained will be available. With ultrasonography and MRI, we now possess two totally non-invasive methods of cardiac exploration, but MRI offers the advantage that its results do not depend on the operator.

[Early results of coronary surgery in patients between 71 and 80 years of age]. / Résultats immédiats de la chirurgie coronarienne entre 71 et 80 ans.

One hundred consecutive patients aged 71 to 80 without other cardiac pathology underwent coronary bypass surgery by the same surgical team between January 1986 and May 1989. These patients were recruited from a group of 687 patients undergoing coronary bypass surgery in the same period. The indication was always based on the severity of clinical symptoms resistant to medical therapy. Recent unstable angina despite triple therapy was a particularly common indication in this group of patients (61%). Preoperative coronary angiography showed a high incidence of triple vessel (62 cases) and left main stem disease (23 cases). Double vessel (12 cases) and single vessel disease (3 cases) were less common. Preoperative myocardial infarction was observed in 35% of cases; the site was nearly always on the inferior wall. In all, 230 bypasses were performed including 23 internal mammary artery bypasses (average 2.3 bypasses per patient). Six patients developed perioperative myocardial infarction confirmed by ECG and a rise in cardiac enzymes in 4 cases and by a rise in the cardiac enzymes alone in 2 cases. The mortality was low in this group of patients (3%). This was due to strict selection of patients in this age group and also to the improvement in the techniques of myocardial protection, anaesthesia and intensive care. Our results justify the operative indications in this group of patients in whom medical therapy has failed.

[Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age]. / Chirurgie cardiaque chez les patients âgés; résultats immédiats et à moyen terme chez 100 patients âgés de 75 ans et plus.

With improved operative technique and postoperative care, progressively older patients are being referred for cardiac surgery. One hundred out of 633 patients operated between September 1990 and December 1992, were over 75 years of age (Group I). These patients were compared with the last 100 patients under 75 years of age (Group II). Both groups were operated by the same surgical team with the same anaesthetic, cardiopulmonary bypass and myocardial protection techniques. The average age of the groups was 79.5 +/- 3.1 and 62.1 +/- 9.2 years, respectively. The procedures performed were: myocardial revascularisation (Group I, 28 cases; Group II, 59 cases), aortic valve surgery alone or associated with coronary bypass (56 and 22 cases respectively), and mitral valve surgery alone or associated with another procedure (11 and 12 cases). There were no significant differences between the two groups with respect to true low output state, the duration of mechanical ventilation and of intensive care and hospital stay. On the other hand, there were significant differences in: the number of blood transfusions (44 cases versus 20, p < 0.001), the occurrence of atrial fibrillation (52 cases versus 29, p < 0.001) and neuropsychiatric disturbances (27 cases versus 5, p < 0.0001). There were no cases of mediastinitis in either group. The hospital mortality was 6% in Group I and 5% in Group II (NS). The medium-term mortality after an interval of 5 to 32 months in the over 75 age group was 7 cases, including 4 cases of cerebrovascular accident. An enquiry was performed in the 87 survivors of Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retrograde cerebral perfusion for replacement of the aortic arch. Apropos of a case]. / Perfusion cérébrale rétrograde pour remplacement de la crosse aortique. A propos d'un cas.

The authors report a case of cerebral protection with retrograde cerebral perfusion during aortic arch surgery. The duration of retrograde cerebral perfusion and the favorable neurological outcome seem to confirm the promising results of this technique developed in Japan.

[Surgical treatment of infectious endocarditis on a native valve. Apropos of 71 cases]. / Traitement chirurgical de l'endocardite infectieuse sur valve native. A propos de 71 cas.

The results of surgery in a series of 71 patients operated upon for infective endocarditis on a native valve are presented. The patients' mean age was 35 years; the initial focus of infection was usually located in the mouth and the most frequent pathogens were staphylococci and streptococci. The aortic valve was most frequently involved. Only 26 patients underwent surgery after 40 days of antibiotic therapy; 34 were operated upon in a semi-emergency and 11 in an acute emergency. Pre-operative systemic embolism was common (20 cases), notably in the brain (17 cases), and 11 patients remained with sequelae. There was good correlation between the anatomical lesions found at surgery and the data obtained from pre-operative echocardiography. The operation was performed on one valve in 40 cases, on two valves in 20 cases and on three valves in 11 cases. Bioprostheses were used more often than mechanical prostheses. Hospital mortality was nil in patient who underwent elective surgery; it was 14.7 p. 100 in those operated upon in a semi-emergency and 27.3 p. 100 in those operated upon in an acute emergency. Nine patients developed late complications, mostly within 6 months of the operation; in particular, prosthesis disinsertion occurred in 4 cases, and progression of a pre-existing left cardiac failure was observed in 2 cases. In their conclusions the authors emphasize the reliability of echocardiography and the need for an early operation in cases with haemodynamic disorders in order to avoid severe myocardial failure and, if possible, systemic embolism and its fearsome sequelae.

[Immediate postoperative results following conservative surgery of rheumatic mitral valve insufficiency in children]. / Resultats postopératoires immédiats après chirurgie conservatrice pour insuffisance mitrale rhumatismale chez l'enfant.

The immediate post-operative results of conservative surgery were evaluated objectively in 31 children aged under 13 years referred to us for surgical correction of severe rheumatic mitral valve regurgitation. 16 patients had pure mitral regurgitation. In the others, lesions which required additional surgery were aortic regurgitation in 7 cases, tricuspid of the mitral valve and left ventricle was studied by two-dimensional TM-mode echocardiography. This examination was combined with a pulsed doppler study in search of a possible residual mitral regurgitation signal, with special attention to the depth at which it was recorded in the left atrium -- a semi-quantitative indication of the severity of residual leakage. Two mitral valve replacements were performed, and two early reoperations were needed for residual regurgitation developed between the 5th and 8th post-operative days. Three deaths occurred due to supra-systemic pulmonary arterial hypertension. The post-operative evaluation of mitral valvuloplasty results therefore involved 25 patients. In the absence of significant residual mitral regurgitation, two-dimensional echocardiography was inconclusive since the images obtained varied considerably according to the surgical procedures performed. There was a distinct reduction of end-diastolic diameters (43.5 +/- 5.9 versus 62.1 +/- 8.7 mm pre-operatively), reflecting the disappearance or marked decrease of the pre-operative ventricular volume overload consecutive to mitral regurgitation. The reduction of end-systolic diameters was also significant (31.2 +/- 6.7 mm versus 39.2 +/- 7.1 mm pre-operatively), though less pronounced than that of end-diastolic diameters, which explains the diminution observed in the percentage of fibre shortening, although the figures remained within normal limits (28.7 +/- 9.7 p. 100 versus 37.0 +/- 6.8 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Hydatid cyst of the right heart and post-embolic pulmonary hypertension]. / Kyste hydatique du coeur droit et hypertension pulmonaire post-embolique.

A 22-year old man with hydatid cyst of the right ventricle presented, for about 10 years, with clinical signs of post-embolic pulmonary hypertension. Despite tumoral resection, the patient died post-operatively of his pulmonary hypertension. Post-mortem examination showed a hydatid cyst on the main pulmonary artery and fixed post-embolic pulmonary hypertension, but we were unable to determine whether we were dealing with old migrated cysts or blood clot emboli developed in contact with the cardiac tumour.

[Syndrome of vagal hypertonia in a newborn infant manifested during the surgical repair of aortic coarctation associated with banding of the pulmonary artery]. / Syndrome d'hypertonie vagale chez un nouveau-né révélé lors d'une cure de coarctation aortique associée à un cerclage de l'artère pulmonaire.

We report a case of vagal hypertonia syndrome in a newborn infant, developed after surgical repair of an aortic coarctation combined with banding of the pulmonary artery trunk. The parasympathetic activity had adverse repercussions on haemodynamics. The diagnosis was confirmed by prolonged asystole on the oculocardiac reflex and by concomitant arrhythmia and disorders of conduction demonstrated by Holter recordings. To our knowledge, no other case of vagal hypertonia associated with a congenital cardiopathy has yet been reported. Infants with this syndrome are at a high risk of sudden death. Treatment with vagolytic drugs is of questionable value, and prolonged supervision of the patient is mandatory.

[Interrupted aortic arch. A series of 15 patients]. / Interruption de l'arche aortique. Une série de 15 patients.

Between 1983 and 1989, 15 children underwent surgical repair of interrupted aortic arch at 1 to 20 days of age. The anatomical form was a Celoria and Patton type B in all patients with an associated perimembranous ventricular septal defect in all but one who had multiple ventricular septal defects, and patent ductus arteriosus. Six children had a retro-esophageal right subclavian artery, two had subaortic stenosis and two had a right-sided descending thoracic aorta. In two children with severe hypoplasia of the ascending aorta the repair was performed in one stage with two deaths due to left ventricular failure. In the other B cases, a two-stage repair was carried out. The reconstruction of the aortic arch varied according to the individual case. All children had pulmonary artery banding. Seven children survived longer than 30 days. Six of them later underwent a complete repair. The only survivors were those patients in whom the neo-aortic arch grew harmoniously. The authors conclude that: a two-stage repair gave disappointing results in this series of consecutive patients, mainly because of the poor quality of the reconstruction of the aortic arch by thoracotomy.

[Atrioventricular valve replacement in congenital cardiopathies. A series of 25 surgically-treated patients under 10 years of age]. / Remplacement des valves auriculo-ventriculaires dans les cardiopathies congénitales. Une série de 25 opérés âgés de moins de 10 ans.

A series of 25 congenital malformations of the atrioventricular valves underwent valve replacement (10 mechanical and 15 bioprostheses). Seven children died during surgery. The operative mortality was higher before 2 years of age (4/7) than in older children (3/18). It was also higher when valve replacement was performed at second intention (5/14) than when decided on from the outset (2/11). With an average follow-up over 3 years, 9 of the 18 survivors are considered to be good surgical results. Of the other 9, 3 are considered to be moderate results (2 associated subaortic stenoses), 3 present indications of reoperation for calcification of the bioprosthesis, and 3 died in the late follow-up period. This series suggests that plastic surgery of congenital malformations of the atrioventricular valves should continue to be developed.

[Abnormalities of the aortic arch in adults. A rare cause of tracheo-oesophageal compression. Apropos of 2 cases]. / Les anomalies des arcs aortiques chez l'adulte. Une cause rare de compression trachéo-oesophagienne. A propos de deux cas.

Two cases of symptomatic aortic arch anomalies in adults are reported: a case of Neuhauser's ligamentum arteriosum with compressive retro-oesophageal diverticulum, and a case of double aortic arch revealed by postoperative tracheal compression. In both cases, surgical correction was made very difficult by the aneurysmal progression of the compressive vascular anomalies and resection of the thoracic aorta under cardiopulmonary by-pass was necessary. These therapeutic difficulties therefore highlight the differences between aortic arch anomalies in adults and those in infants which can be simply and effectively treated with no mortality in our experience. These observations argue in favour of systematic surgical correction of any aortic arch anomalies in infants, even when they are responsible for few symptoms.

[Phrenic nerve palsy after heart surgery. The Bichat Hospital experience]. / Paralysies phréniques après chirurgie cardiaque. Expérience de l'Hôpital Bichat.

The frequency of phrenic nerve palsy varies from 2.5 to 8.3%, according to different authors. Contact of the phrenic nerve with cold (ice or saline) seems to be the most frequent etiology. This study points out that good insulation between phrenic nerve and ice slush, used in the pericardium, results in almost complete disappearance of this complication, which is not a benign one, as emphasized by the two deaths in our series.

[Long-term retrograde cerebral perfusion in surgery of the aortic arch. Apropos of 2 cases]. / Perfusion cérébrale rétrograde de longue durée dans la chirurgie de la crosse aortique. A propos de deux cas.

The authors present two cases of aortic arch replacement for aortic dissection: one in a male patient 58 years old and the other in a female patient 78 years old. Cerebral protection during repair of the aortic arch was performed with retrograde cerebral perfusion (RCP). Durations of RCP were 75 and 120 minutes respectively. Good neurological recovery in both patients appeared to confirm the efficacy of RCP with respect to cerebral protection during surgery of the aortic arch.

[Iloprost (Ilomedine) and extracorporeal circulation with conventional heparinization in a patient with heparin-induced thrombocytopenia]. / Iloprost (Ilomédine) et circulation extracorporelle avec héparinisation conventionnelle chez un patient ayant une thrombopénie à l'héparine.

A 73-year-old female patient was admitted for myocardial infarction. Conventional treatment with heparin was started, intraaortic balloon assistance was required for several days, together with heparin. The platelet counts decreased progressively, from 288 G.l-1 on admission to 41 G.l-1 on the 16th day, despite the use of low molecular weight heparin. The in vitro heparin platelet aggregation test remained positive. This aggregation ended on adding iloprost, an analogue of prostacyclin, to the platelet culture bath. A coronary aortic bypass graft was required. An infusion of iloprost was started just after induction of anaesthesia. The initial dose of 0.5 ng.kg-1 x min-1 was gradually increased to 20 ng.kg-1 x min-1. Heparin (400 IU.kg-1) was thereafter added. To maintain a mean blood pressure of a least 50 mmHg, an infusion of up to 10 micrograms.kg-1 x min-1 of phenylephrine was given. As it was insufficient, an infusion of up to 1 microgram.kg-1 x min-1 noradrenaline was required. The iloprost infusion was gradually stopped 15 min before the end of CPB, together with that of noradrenaline. Platelet aggregation tests were positive after protamine had been given, whereas they had been negative during the infusion of iloprost. There was no abnormal postoperative bleeding. An infusion of 2 ng.kg-1 x min-1 was started at the sixth postoperative hour for 48 h, until the coumarin-like agent had started taking its effects. It is concluded that iloprost might be useful for carrying out cardiac surgery in patients with heparin-induced thrombocytopaenia.