Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers.

Nasal continuous positive airway pressure (N-CPAP) is now the treatment of choice for patients with sleep apnea syndrome (SAS). Side effects and adverse reactions have been described with this device. We have therefore systematically studied side effects of N-CPAP in 193 patients recruited consecutively from two French sleep centers (Lyon and Grenoble). Patients were followed up with repeated polysomnography, clinical assessment, and a formal questionnaire about subjective benefits and side effects of treatment. The patients (mean age, 59 +/- 12 years) were obese (body mass index, 32 +/- 7 kg/m2) and had been using N-CPAP for 19 +/- 17 months for moderate to severe SAS (respiratory disturbance index [RDI] = 53 +/- 25/h). The clinical presentation was the same in the two sleep centers. Fifty percent of the patients complained of at least one side effect due to the nasal mask (allergy to the face, air leaks, abrasions of the ridge of the nose). Using individually molded masks, the patients exhibited fewer abrasions of the bridge of the nose (p < 0.01) and had red eyes every morning in only 9% of cases vs 24% for the patients using industrial silicone nasal masks (p < 0.025). Patients with silicone nasal masks also had more allergic reaction to the face (13% vs 5%), but this difference did not reach significance. Dry nose or mouth in the morning affected 65% of the patients. Sneezing and nasal drip were present in more than 35% of the subjects and nasal congestion in 25%. When the patients were separated in two groups, whether or not using a humidifier, no difference was found for any of the side effects described. The clinical presentation as to the clinical benefits obtained from N-CPAP were different when comparing mild vs moderate-to-severe SAS. However, no differences were shown in the two subgroups regarding the side effects due to the nasal mask. The discomfort of the N-CPAP apparatus in terms of noise was described more frequently in the subgroup with mild SAS. We did not observe any correlation between the side effects and the level of pressure used during N-CPAP. The rate of compliance remains high with a daily use of 6.5 +/- 3 h, with 88% of the patients using their device every night. This could be explained by the clinical benefit obtained: only 1% of the patients had no subjective benefit induced by their therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Current problems in cardiac transplantation.

Since our initial orthotopic heart transplant (OHT) in 1968, the first in Europe, 1130 patients with ages ranging from 1 month to 66 years have been referred to us. The cause of irreversible myocardial damage was idiopathic cardiomyopathy in 74%, ischemic heart disease in 19% and left ventricular failure after valvular replacement in 7%. A total of 540 transplantations, 463 orthotopic, 40 heterotopic and 37 heart-lungs were carried out. Features of the early post-operative course include temporary (first week) cardiac instability treated by isoproterenol. Later complications included rejection (95%) and side-effects of immunosuppressive therapy; infection (83%), osteoporosis, malignancy, graft atherosclerosis (2%). Cyclosporine (Cy) was responsible for diastolic hypertension, renal dysfunction, hirsutism, hyperplasia of the gingiva, hepatic dysfunction, and seizures. The survival rate of the Cy-treated patients was 68% at 7 years. All survivors have virtually normal social and professional lives, included the longest survivor 14 years after the operation. Recently in 34 patients in acute irreversible cardiac failure and who cannot have a transplant in time, we implant a total artificial heart (TAH) type JARVIK 7 during a period from 1-150 days. There has been no mechanical failure, hemolysis or thrombo-embolism and only one right ventricular device malposition; 20 patients died before transplantation, 13 were successfully transplanted, 1 is still on the artificial heart. Heart transplantation, and TAH used as a bridge to transplantation are now an accepted therapeutic means for irreversibly cardiac failure in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Expanded polytetrafluoroethylene membranes to wrap surfaces of circulatory support devices in patients undergoing bridge to heart transplantation.

OBJECTIVE: Because of a lack of donor hearts, an increasing number of patients with heart failure must now undergo bridge to cardiac transplantation with a mechanical circulatory support device. Moreover, support periods have become longer. As a result, pericardial adhesions may develop while the support device is implanted, increasing the risk of injury at resternotomy and bleeding after transplantation. Use of expanded polytetrafluoroethylene (ePTFE) pericardial substitutes (membranes) may prevent such adhesions. PATIENTS AND METHODS: From January 1997 to December 1999, ePTFE membranes were used in 23 patients to wrap portions of an implanted left ventricular assist device (LVAD) or total artificial heart (TAH). Any complications during mechanical support or at cardiac transplantation were recorded. Six ePTFE membranes removed at transplantation were studied histologically. RESULTS AND CONCLUSIONS: At resternotomy for transplantation, the plane of dissection between tissues, ePTFE membranes, and surfaces of the mechanical support device were easily discerned. No adhesions were observed between tissues and membranes. There were no injuries during resternotomy and no patient had to undergo reoperation because of bleeding. One patient given a TAH had an infection during circulatory support that was controlled by antibiotic therapy. In another patient, clots developed between the device and an ePTFE membrane; these were removed successfully. Histologic studies of removed ePTFE membranes showed no infiltration of the membranes interstices by collagen or cellular components. Use of ePTFE membranes in patients undergoing bridge to transplantation with either an LVAD or a TAH limited adhesions between tissues and device surfaces without increasing the risk of infection.

[Mediastinitis caused by anaerobic bacteria. 4 cases]. / Médiastinites à germes anaérobies. Quatre observations.

In 4 cases of mediastinitis caused by anaerobes and consecutive to dental abscess (2 cases), perforation of the oesophagus and tonsillar abscess, the diagnosis was based on widening of the mediastinum associated, in 2 cases, with pneumomediastinum. II all 4 cases, Bacteroides fragilis was present among other germs. Treatment consisted of surgical drainage by thoracotomy (2 cases), or cervicotomy and antibiotic therapy. Two of the patients, who were old and had underlying diseases, died.

Approach to advanced aortic root infection.

Among our first 11,620 cases of valvular replacement, we observed 285 cases of valvular endocarditis and 59 cases (20.7%) in which the importance of the infectious lesions of the aortic or mitral annulus required complex valvular repair. In 23 patients with aortic valvular endocarditis, the presence of an abcess of the aortic annulus required its closure with a patch resulting in one early and one late death and five reinterventions with one death. Twenty patients are alive and well, 1 to 9 years after operation. In 11 patients, the extent of annular abcesses required the insertion of a subcoronary valved conduit. After a maximum follow-up of 8 years there were two early deaths, two late deaths, one reoperation, and seven good results. Twelve patients had a supracoronary valved conduit resulting in four early deaths, one late death, and two reoperations; seven are alive and well, 2 to 6 years later. Three patients previously operated on had a left ventricular abdominal aorta valved conduit, two of them are alive and well up to 6 years later. Severe infectious lesions of the valvular rings (aortic root) can require complex repairs that can be lifesaving and provide excellent long-term results.