Evaluation of a cardiopulmonary preservation method for heart-lung transplantation.

This study was designed to examine whether concomitant administration of anti-free radicals with donorcore cooling on cardiopulmonary bypass (CPB) and hypothermic storage of the heart and lung, could provide successful extended cardiopulmonary preservation. Fourteen sheep heart-lung blocks harvested after core-cooling and cardioplegic arrest were preserved at 4 degrees C for 8.5 hr. Before and during CPB, the animals were perfused with Prostaglandin E1 (PGE1), superoxide dismutase (SOD), catalase (CAT) and deferoxamine (DEF). Cardioplegic arrest was induced with St. Thomas' Hospital solution (Plegisol) to which SOD, CAT and DEF had been added. The preservation solution consisted of Plegisol modified by the addition of K-lactobionate, raffinose, mannitol, SOD, CAT, DEF, a phosphate buffer and penicillin. Histological examination performed on 3 donor heart-lung blocks before and after CPB and cardioplegia, then immediately following cold storage, produced no clear evidence of structural damage in cardiac myocytes and lung parenchyma. Eleven donor organs were therefore transplanted in size-matched recipients with a total mean ischemic time of 12 hr. The combined administration of SOD, CAT, DEF, insulin and glucose during the initial period of reperfusion had no beneficial effect on cardiopulmonary performance. A progressive fall in Pa O2 and mean aortic pressure was observed post-operatively in the 7 animals that were weaned from CPB. Five of them died within 3 to 5 hr after CPB weaning, the remaining 2 animals died of cardiac arrest within the fourth hour. The results of this experiment seem to indicate that: 1. better organ function and improved survival could have been obtained if the duration of anti-radical treatment had been prolonged after reperfusion and, 2. physical manipulation of the donor grafts during harvesting and transplantation may have been partly responsible for the poor post-transplantation cardiopulmonary performance.

Cardiac surgical aids: heart cup and stentless valve holder.

We present two new cardiac surgery instruments that we perfected in our department. The heart cup holds the donor's heart vertically within a cold saline solution, thus allowing adequate preparation of the heart for transplantation, as well as the excision of valvular homografts from the recipient's heart. The stentless valve holder is used to hold valvular homografts to ease both their preparation and implantation.

[Lower limb arteriopathy and male osteoporosis]. / Artériopathie des membres inférieurs et ostéoporose masculine.

There are close links between bone metabolism and bone circulation. Osteoblasts are derived from the walls of the venous sinuses. As shown by Burkardt, osteoporosis is accompanied by a decrease in the number of intra-osseous capillaries, and intra-osseous arterioles may be the site of arteriosclerosis lesions. In order to determine the existence of a possible link between arteriosclerosis and male osteoporosis, the etiology of which is often poorly defined, the authors studied phosphorus-calcium balance, X-rays of the spine, and bone density of the spine and the femoral neck in 17 male arterial disease sufferers with a mean age of 61 and at Leriche stage 2, 3 or 4. These 17 patients were compared with 15 age-paired controls. Wedge fractures, absent in the control group, were seen in 9 of the 17 patients. Bone mineral content in the femoral neck was significantly reduced in the arterial disease group.

Early postoperative sternal approximation after ITA harvesting: computed tomographic evaluation.

Between November 1989 and February 1990, 66 randomized sternotomized patients underwent aortocoronary bypass and were subjected to a sternal scanner in the early postoperative period. Each examination included a manubrial and a sternal body print. At each level, we studied the occurrence of spacing or misalignment of the sternal layers. The 66 patients were subdivided into four groups according to the type of conduit harvested (single left internal thoracic artery or saphenous vein) and the type of material used for the sternal closure (steel wires or nylon yarns). In all cases, adequate early sternal approximation, which is represented by a good alignment as well as by an excellent contact of the sternal layers, was infrequently demonstrated. Moreover, the two abnormalities most often observed were manubrial spacing and sternal body misalignment. The sternal closure technique and internal thoracic artery harvesting had no significant effect on the sternal approximation. To minimize manubrial spacing and sternal body misalignment, we propose that the surgeon should apply three threads through the manubrium, withdraw the shoulder roll beforehand, elevate both of the patient's shoulders, and maintain the two xyphoid layers in the same plane and in fairly close contact during the tightening of the wires.

A new device: the quick cannulation system.

We describe a new technique for the placing and fixing of extracorporeal circulation cannulae in the heart. Two devices are involved, the first for an atrial or venous return cannula and the second for an aortic perfusion cannula. These allow quick easy cannulation which is very important in emergency surgery.

[Heart-lung preservation: historical evolution and current research data]. / Historique de la préservation du bloc coeur-poumons et état actuel de la recherche.

Over the past decade, combined, heart-lung transplantation has been established as a therapeutic modality for many patients with end stage cardiopulmonary disease. However, the scarcity of suitable donors and the lack of a reliable and simple technique for distant organ procurement have somewhat limited its practice. The normothermic autoperfusion preparation has been utilized in a few satisfactory distant heart-lung preservation and subsequent transplantation, but this method is rather cumbersome. Single cold flush perfusion of the pulmonary artery with infusion of prostaglandin E1, a powerful vasodilator of the pulmonary bed, has been used successfully in heart-lung preservation for transplantation. Donor core-cooling through cardiopulmonary bypass without pulmonary artery flush perfusion appears to provide longer and better graft protection since it improves its function. The production of oxygen radicals after reperfusion of ischemic tissues has important implications in organ preservation and transplantation. Recent studies in the prevention of reperfusion injury indicate that enzymatic scavenger and iron chelator therapy may play an important role in the reduction of reperfusion injury in the clinical setting of heart-lung transplantation.

[Malignant fibrous histiocytoma of the right ventricle and pulmonary artery. Apropos of a case. Review of the literature]. / Histiocytome fibreux malin ventriculaire droit et de l'artère pulmonaire. A propos d'un cas. Revue de la littérature.

The authors report a case of malignant cardiac fibrohistiocytoma involving the right ventricular infundibulum and the pulmonary artery and responsible for a pseudo-thromboembolic right heart failure syndrome. Following discovery of the tumour mass on ultrasonography and catheterisation, wide excision of the pulmonary artery, pulmonary valve and the roof of the infundibulum as far as the middle part of the ventricle was performed under cardio-pulmonary by-pass. Reconstruction was performed with a valveless woven Dacron tube. The postoperative course was uncomplicated and the patient was still alive after 18 months. Histology revealed malignant fibrohistiocytoma. The authors also present a review of the literature of these rare tumours of the right-sided cavities (5 cases reported).

Isolated aneurysm of the left sinus of Valsalva. Rupture into the left atrium, left ventricle and dynamic coronary constriction.

Aneurysms of the left sinus of Valsalva are exceptional. They may cause aortic regurgitation and may rupture into an extra or intra-cardiac location. We report an aneurysm of the left Sinus of Valsalva associated with 3 unusual complications: rupture into the left atrium, infected rupture into the left ventricle inducing aortic regurgitation and compression of the left circumflex coronary artery. These caused cardiac failure, coronary insufficiency and paroxysmal ventricular fibrillation. A review of the literature on the LASV has been undertaken.

[Cardiac tumor mass. Diagnostic and therapeutic approach. Apropos of 46 cases]. / Masse tumorale cardiaque. Approche diagnostique et thérapeutique. A propos de quarante-six cas.

The authors analyse a series of 46 operated intracardiac tumours (0.4% of all cases of cardiac surgery). The predominant symptoms were episodes of heart failure and pseudo-valvular disease. Peripheral emboli and pericardiac syndromes with tamponade occurred more rarely and constituted surgical emergencies. Non-invasive investigations, dominated by echocardiography, allow early diagnosis. The majority of tumours were situated in the left atrium and consisted, histologically, of myxomas, the surgical treatment of which consists of wide excision of the pedicle. Malignant tumours (17.7%) were dominated by cardiac sarcomas. When possible, extensive resection of these tumours may improve the chances of medium-term and long-term survival. The operative mortality was 8.8%. The delayed mortality was due to malignant tumours (17.3%). Myxomas must be followed in the long-term by systematic echocardiography. The authors observed 11% of recurrences occurring after a interval of 12 to 144 months (3 cases).

[A large vascularized allograft of the femoral diaphysis in man]. / Une allogreffe massive vascularisée de diaphyse fémorale chez l'homme.

A fresh vascularised femoral allograft was used to replace a 27 centimetre section of the diaphysis of the femur following a crush injury in a 35 year old man. The technique of operation and details of management are described. After nine months the graft junctions were incorporated, and vascular perfusion was satisfactory.

Abdominal aortic aneurysmectomy in octogenarian patients.

The authors report 56 patients. 80 years of age or older who had an abdominal aortic aneurysm (AAA): twenty seven were operated upon as emergencies, 7 with intra-peritoneal (Group I) and 20 with retro-peritoneal rupture (Group II). Twenty nine underwent elective surgery (Group III). Renal pulmonary and cardiac disease are frequent in octogenarian patients. The surgical repair consisted of 40 knitted bifurcated grafts and 16 aorto-aortic woven grafts. The overall in-hospital mortality rate is high (28.5%: 16 patients) essentially in "emergency" surgery: 71% for the seven Group I patients and 45% for the twenty Group II patients. The in-hospital mortality rate of 6.9% for the Group III of "elective" procedure is higher than the mortality rate of patients of all ages operated on for asymptomatic AAA in our institution which is 4.3%. Once a patient has been operated on successfully his life expectancy tends to parallel that of a normal population for his age group. These results can be improved with preventive measures such as elective surgery for asymptomatic AAA with a diameter of 6 cm or more. Operative contraindications are severe congestive heart failure, advanced pulmonary disease or neoplastic disease. The age "per se" is not a contraindication to aneurysmectomy. Physiologic rather than chronologic age should determine the selection for AAA in the over-80 age group. CT scans and MR are safe fast and non-invasive preoperative examinations for AAA.

[Malignant fibrous histiocytoma of the right ventricle and pulmonary artery. Apropos of a case. Review of the literature]. / Histiocytome fibreux malin ventriculaire droit et de l'artère pulmonaire. A propos d'un cas. Revue de la littérature.

The authors report a case of malignant cardiac fibrohistiocytoma involving the right ventricular infundibulum and the pulmonary artery and responsible for a pseudo-thromboembolic right heart failure syndrome. Following discovery of the tumour mass on ultrasonography and catheterisation, wide excision of the pulmonary artery, pulmonary valve and the roof of the infundibulum as far as the middle part of the ventricle was performed under cardio-pulmonary by-pass. Reconstruction was performed with a valveless woven Dacron tube. The postoperative course was uncomplicated and the patient was still alive after 18 months. Histology revealed malignant fibrohistiocytoma. The authors also present a review of the literature of these rare tumours of the right-sided cavities (5 cases reported).

New helper instrument in cardiac surgery.

A new instrument has been designed for cardiac surgery. It frees the hands of the surgical assistant and is effective either for valve replacement or coronary graft anastomosis. The use of this instrument makes the operation quicker and easier.

[Interventional radiology and vascular pathology]. / Radiologie interventionnelle et pathologie vasculaire.

Percutaneous transluminal angioplasty (PTA) has been an important step in the therapy of arterial diseases. Nowadays, it opens the way to new techniques which main goals are to improve the PTA results and to enlarge the indications. This article review these new techniques. The principles, the therapeutic possibilities, the advantages and the inconvenience of each are evaluated, based upon the personal experience of the authors, the bibliography of current literature and the proceedings of a meeting organized on this topic (Toulouse, February 1988). All these procedures are encouraging and let foresee new possible therapy in vascular pathology.

Cardiac damage in nonpenetrating chest injuries. Report of 5 cases.

The Authors report 5 cases of cardiac injury after blunt chest trauma: (a) one right atrial disruption with acute tamponade treated successfully; (b) two left ventricular perforations with rib fractures: one patient was exsanguinated and died, the other one presented a late subacute cardiac tamponade with successful operative repair; (c) one isolated traumatic tricuspid insufficiency which was well tolerated; (d) one atrio-inferior caval disruption with acute tamponade. Cardiac damage secondary to nonpenetrating chest trauma is uncommon but with the present modes of high speed transportation they are occurring with increasing frequency; correct management of cardiac ruptures depends upon rapid recognition of the injury and expeditious surgical repair. The occurrence of tricuspid valvular lesions alone as a result of nonpenetrating trauma is not common. Echocardiographic examination after blunt chest trauma is a useful diagnosis procedure.

Primary malignant fibrous histiocytoma of the right ventricle and main pulmonary trunk with a review of the literature.

We report the case of a 76-year-old man with a malignant fibrous histiocytoma of the right ventricle and main pulmonary trunk, diagnosed through echocardiography and catheterization. Extensive resection of the right ventricular outflow tract, pulmonary valve apparatus, and main pulmonary trunk was performed, and the defect was repaired with a valveless ventriculo-pulmonary Dacron graft. The patient recovered uneventfully, and was doing well 18 months after surgery. To our knowledge, this is only the 15th case of primary malignant fibrous histiocytoma of the heart that has been documented in the literature since histologic criteria and cases were published in 1977-78, and the 2nd such case of a primary tumor that has arisen in a right cardiac chamber. The case is presented in detail, along with a review of the literature since 1978.