[Cardiac surgery without transfusion in 2005]. / Chirurgie cardiaque sans transfusion en 2005. A propos d'une série de 200 témoins de Jehovah opérés.

PURPOSE: Between January 1991 and October 2003, 200 Jehovah Witnesses adult patients underwent elective cardiac surgery. To asses the impact on continuing progress of blood saving protocols and the increasing operative risk of patients proposed to surgery, we have re-assessed our results in this specific population. METHODOLOGY: Files of the first 100 patients operated upon between 1991 and 1998 were reviewed, and compared to the following 100 ones treated between 1998 to today. All patients were scored using the Euroscore model. RESULTS: In the latest series, patients are older (68 vs 51) and 13% underwent an iterative procedure, although there was none in the first series. Three deaths occurred after one month at the beginning of our experience, only one in the latest series. Operative risk factors had distinctly deteriorated, with more redux, and ejection fraction lower than 35%. Major progress to maintain morbi-mortality stability were multifactorial: preoperative erythropoietin in order to reach an haemoglobin minimal value of 14 g/dL, Cornell University protocol, mini-ECC, warm blood cardioplegia, ultra-early extubation. CONCLUSION: Cardiac surgery without transfusion can be realised with an equivalent risk to that of classical surgery, despite an operative risk aggravation, due to the association of recent conservative techniques.

Dobutamine: a hemodynamic evaluation in human septic shock.

The hemodynamic effect of dobutamine infusion (DI) was studied in 19 patients with septic shock. DI resulted in hemodynamic improvement as indicated by a significant increase in cardiac index (+36%, p less than 0.001), stroke index (+15%, p less than 0.01), mean arterial pressure (+20%, p less than 0.01), and a significant decrease in aVDO2 (-27%, p less than 0.01). This hemodynamic improvement occurred concomitantly with a fall in both right and left filling pressures. Mean systemic arterial resistance remained unchanged with a scatter of individual responses depending on other factors, such as infusion rate, initial vascular resistance, and underlying hemodynamic setting. In patients mechanically ventilated, venous admixture in the lung (Qs/Qt) during DI increased significantly (+30%, p less than 0.001) and insignificantly reduced PaO2, but this adverse effect was not observed when PEEP was used in patients mechanically ventilated. It is concluded that dobutamine can be useful in management of septic shock, particularly when filling pressures are high because of fluid overload or cardiac failure.

Controlled ventilation with best positive end-expiratory pressure (PEEP) and high level PEEP in acute respiratory failure (ARF).

We assessed hemodynamics, total lung and chest wall compliance (CT) and gas exchange using two different levels of PEEP during controlled ventilation in two different groups of patients with ARF; in the first group (Group 1, 12 patients) chest X-Rays showed a symmetrical pattern of bilateral alveolar infiltrates; in the second group (Group 2, 5 patients) chest X-Ray showed a asymmetrical pattern with unilateral lobar consolidation. A first level of PEEP (best PEEP = 9 +/- 3 cm H2O) produced an improvement in CT and in gas exchange with a slight decrease in cardiac index in both groups; but improvement in PaO2 (from 64 +/-33 to 122 +/- 76 torr, p less than 0.001 in Group 1, and from 76 +/- 39 to 91 +/- 33 torr, p less than 0.05 in Group 2) and decrease in QS/QT were not as well marked in Group 2 as i Group 1. A second level of PEEP (high level PEEP: 20 +/- 4 cm H2O) produced a sharp decrease in CT and required hemodynamic support in each case (blood volume expansion with or without Dopamine infusion) to maintain cardiac index within a normal range. In Group 1 this high level PEEP produced a greater improvement in gas exchange (PaO2 increased from 122 +/- 76 to 194 +/- 76, p less than 0.01) but in Group 2 it had a deleterious effect, producing a decrease in PaO2 (from 91 +/- 33 to 76 +/- 41 torr, p less than 0.05), and an increase in QS/QT; with this higher PEEP we also noted an increase of alveolar dead space in Group 2. This study demonstrates the efficiency of high levels of PEEP to reduce QS/QT in ARF but also shows its limitations: namely reduction in cardiac performance and in efficiency if the damage to one lung is significantly more pronounced than that to the other lung.

[Dissecting aneursym of the ascending aorta after lateral clamping for aorto-coronary by pass (author's transl)]. / Dissection de l'aorte ascendante après clampage latéral pour pontage aorto-coronaire.

Four cases of dissecting aneurysm of the aorta after lateral aortic clamping for aorto-coronary bypass are described. These accidents are rare but very serious. They often occur in hypertensive patients, and sometimes an aortic wall with a low elastic fibre content is found on histology. Surgery is that of dissecting aneurysm of the ascending aorta. However the severity of these accidents should lead to routine preventive measures during all aortocoronary bypass operations, in particular aortic anastomosis of the grafts under extra-corporeal circulation.

[Re-operation for myocardial revascularisation. 15 cases (author's transl)]. / Réinterventions pour revascularisation myocardique. 15 observations.

Among 1110 patients undergoing aorto-coronary bypass procedures, 15 required late re-operation (average interval 28 months) for myocardial revascularisation. This was performed following the recurrence of anginal symptoms, on average 15 months after the first operation. Six resections of localised stenosis of the vein graft and eleven "new" aorto-coronary bypass were performed. One patient died early, 12 hours after surgery, while 2 died 3 and 26 months later. Nine of the 12 survivors had no symptoms 4 to 63 months after the re-operation. Thus in the presence of angina recurring after aorto-coronary bypass, a new follow-up coronary arteriogram should be performed in order to seek lesions which might benefit from further attempted surgical treatment.