[Veno-venous extracorporeal oxygenation and veno-arterial extracorporeal oxygenation. Questions, answers]. / Assistance respiratoire veino-veineuse et assistance circulatoire veino-artérielle avec oxygénation extracorporelle. Questions, réponses.

A round table, organized by the French Society of Perfusion (Sofraperf) at the French national congress on extracorporeal circulations (Perfusion 2013), was attended by perfusionists, anaesthesiologists, intensivists and surgeons around the theme of respiratory veno-venous support and veno-arterial circulatory support with extracorporeal oxygenation in intensive care units. The debate was conducted in a participatory manner by bi-directional questions-answers session between moderators and assistance. The authors report management of this type of therapy that is not perfectly homogeneous, supported on literature data. Cannulae, cannulation, circuit, oxygenator, anticoagulation, control, surveillance, weaning are subject to paragraphs with defined entry whose contents are mutually enriching.

[Vasomotor tone and CBP : monitoring components, pratical and therapeutic approaches]. / Tonus vasomoteur et CEC : éléments de surveillance, attitudes pratique et thérapeutique.

The vasomotor tone is an essential determinant of blood pressure. Vascular resistance is the result of a calculation including vasomotor tone, blood flow and blood viscosity. The vascular tone is modulated by the sympathetic system and the direct actions of drugs (patient's pathology, anaesthesia). The pressure and flow allow the vascular tone apprehension. A decrease in vasomotor tone lowers the mean arterial pressure and may cause an intense vasoplegia with arterial vascular resistance below than 800 dyn/s/cm(5) leading to a lack of tissue oxygenation. Vasomotor paralysis can be caused by the patient medications or an intense inflammatory reaction starting at the extracorporeal circulation onset. Monitoring parameters of extracorporeal circulation such as pressure, flow, arterial and venous oxygen saturation, blood level in the venous reservoir, and extensively blood gases, haemoglobin, CO(2) partial pressure level of the oxygenator vent, bispectral index, and oxygen saturation of cerebral tissue are reviewed. They will know the vasoplegia consequences and bear an indication of adequate tissue oxygenation. It may be obtained by using vasopressors (ephedrine, norepinephrine, terbutalin and vasopressin) methylene blue, increasing blood viscosity (erythrocytes) and blood flow, even by inducing hypothermia.

[Traumatic aortic regurgitation: diagnostic, management and treatment]. / Rupture traumatique de la valve aortique. Diagnostic, prise en charge et traitement.

Traumatic aortic valve regurgitation is a rare complication of non-penetrating thoracic trauma. The most frequent lesion is the isolated injury of the non-coronary cusp. Actually, the transoesophageal echocardiography is the procedure of choice to confirm the diagnosis and to reveal the associated cardiovascular lesions. Surgical management with early operation is the best policy, however this surgery can be delayed for treatment of other life-threatening injuries. Up today, aortic valve replacement (AVR) was recommended to repair traumatic aortic valve regurgitation; nevertheless, in the recent international literature, the number of cases reports with conservative surgery (CS) is increasing: 10 AVR (group I) and 10 CS (group II). Analysis of the post-operative and long term periods shows good results: it confirms the excellent clinical evolution in the group I (mean time of follow-up: 18.2 +/- 16.3 months), and reveals satisfactory results in the group II for patients with isolated lesion (mean time of follow-up: 29.1 +/- 30.7 months). In conclusion, each time the traumatic aortic regurgitation is due to an isolated lesion, the conservative surgery should be performed in order to avoid aortic valve replacement and its potential complications especially in young patients with healthy valves. However, the aortic valve replacement is the safest technique for complex or multiple injuries of the aortic valve.

Traumatic aortic regurgitation: aortic valvuloplasty controlled by aortoscopy.

Traumatic aortic insufficiency is a rare occurrence after blunt chest trauma, and requires surgical treatment. Aortic valve replacement has been proposed as the procedure of choice, but primary valve repair is being performed increasingly more often. In a plead for conservative surgery, we report a case of valvuloplasty that was controlled by intraoperative aortic endoscopy. When operative conditions permit aortic valve repair, this should be carried out in order to avoid aortic valve replacement and its potential complications, especially in young patients with healthy valves. Replacement is the safest treatment for complex or multiple injuries of the aortic valve, however.

[Pulmonary lymphangioleiomyomatosis. Immunohistochemical and ultrastructural study of two cases]. / La lymphangioléiomyomatose pulmonaire. Etude immunohistochimique et ultrastructurale de deux observations.

The authors report two cases of pulmonary lymphangioleiomyomatosis which were diagnosed by surgical biopsies. Immunohistochemical study showed positive staining of the smooth muscle cells using antibodies directed against smooth muscle actin, specific muscle actin, HMB45 and vimentin. Ultrastructural study showed some smooth muscle differentiation features, with numerous myofilaments and some dense bodies near the plasma membrane. In one case, the patient was treated by a double-lung transplantation. LAM is a non-familial disease occurring exclusively in females. The etiology is unknown. This disease can be complicated by chronic respiratory failure. Extrapulmonary sites are not rare, particularly in the uterus. Anti-estrogen treatment can slow the course of the disease. Lung transplantation is actually the only effective treatment at the present time therapy. The differential diagnosis of this disease is discussed.

Economia transfusional en cirugía cardíaca, rol de la aprotinina y el ácido tranexámico / Reduction of homologous transfusion requirements with aprotinin or tranexamic acid in cardiac surgery

Las pérdidas hemorrágicas y las necesidades de transfusión sanguínea homólogas son comparadas en tres grupos de pacientes operados en Cirugía Cardíaca bajo Circulación Extra-Corpórea (CEC), recibiendo aprotinina (grupo A), ácido tranexámico (grupo T) o formando el grupo control (grupo C). El protocolo randomizado prospectivo y abierto, fue aprobado por el Comité de Etica del Hospital. El estudio comprende 100 pacientes. Los tres grupos son comparables en edad, sexo, patología, duración de la CEC y del clampaje aórtico. El grupo A recibió 500.000 UIK de aprotinina a la inducción de la anestesia, más 500.000 UIK/hora durante la CEC. El grupo T recibió 15 mg/kg de ácido tranexámico en dos veces; a la inducción de la anestesia y al fin de la CEC. El grupo C no recibió ningún antifibrinolítico. El volumen total de pérdidas drenadas en el período postoperatorio, fue menos importante en el grupo A (486 + 340 ml) y en el grupo T (482 + 345 ml) que en el grupo C (819 + 573 ml) p < 0,01. El número de pacientes transfundidos fue más importante en el grupo C (20/32) que en grupo A (12/33) y el grupo T (11/35) p < 0,05. La aprotinina y el ácido tranexámico reducen en 40 por ciento las pérdidas hemorrágicas en el postoperatorio de cirugía cardíaca bajo CEC. Las necesidades transfusionales fueron reducidas en un 50 por ciento en los grupos A y T comparados con el grupo C.

Economia transfusional en cirugía cardíaca, rol de la aprotinina y el ácido tranexámico / Reduction of homologous transfusion requirements with aprotinin or tranexamic acid in cardiac surgery

Las pérdidas hemorrágicas y las necesidades de transfusión sanguínea homólogas son comparadas en tres grupos de pacientes operados en Cirugía Cardíaca bajo Circulación Extra-Corpórea (CEC), recibiendo aprotinina (grupo A), ácido tranexámico (grupo T) o formando el grupo control (grupo C). El protocolo randomizado prospectivo y abierto, fue aprobado por el Comité de Etica del Hospital. El estudio comprende 100 pacientes. Los tres grupos son comparables en edad, sexo, patología, duración de la CEC y del clampaje aórtico. El grupo A recibió 500.000 UIK de aprotinina a la inducción de la anestesia, más 500.000 UIK/hora durante la CEC. El grupo T recibió 15 mg/kg de ácido tranexámico en dos veces; a la inducción de la anestesia y al fin de la CEC. El grupo C no recibió ningún antifibrinolítico. El volumen total de pérdidas drenadas en el período postoperatorio, fue menos importante en el grupo A (486 + 340 ml) y en el grupo T (482 + 345 ml) que en el grupo C (819 + 573 ml) p < 0,01. El número de pacientes transfundidos fue más importante en el grupo C (20/32) que en grupo A (12/33) y el grupo T (11/35) p < 0,05. La aprotinina y el ácido tranexámico reducen en 40 por ciento las pérdidas hemorrágicas en el postoperatorio de cirugía cardíaca bajo CEC. Las necesidades transfusionales fueron reducidas en un 50 por ciento en los grupos A y T comparados con el grupo C. (AU)

[An unusual pericardial tumor: bronchogenic cyst]. / Une tumeur péricardique inhabituelle: le kyste bronchogénique.

The authors report the case of an intrapericardial bronchogenic cyst in a 42 year old woman with no cardiac symptoms. Despite extensive investigation, the final diagnosis was made only at anatomopathological examination. A pericardial localisation of this embryological tumour is very rare and a number of features of the condition are described. In this case, the carbohydrate antigen (CA 19-9) was a veritable marker of this tumour. This association, described for the first time, between a simple biological marker and an intrapericardial bronchogenic cyst, could be a valuable diagnostic aid in a pathology in which surgery could reasonably be deferred should the diagnosis of bronchogenic cyst be certain.

[Thrombocytopenia induced by heparin and cardiac surgery with extracorporeal circulation]. / Thrombopénie induite par l'héparine et chirurgie cardiaque sous circulation extracorporelle.

A case of mitral and aortic valvular replacement combined with double coronary artery bypass grafting is reported in a 64-year-old woman who presented with a history of heparin-induced thrombocytopenia. The use of a conventional dose of heparin did not induce the formation of a plasma platelet-aggregation factor. The necessity of postoperative anticoagulation was ensured by the prescription of antivitamin K, started on the morning of the operative day.

[Aorto-coronary bypass and defibrination after thrombolysis during the acute phase of myocardial infarct]. / Pontage coronarien et défibrination après thrombolyse à la phase aiguë d'un infarctus du myocarde.

Coronary bypass was carried out in four patients who have received an intracoronary streptokinase infusion for acute myocardial infarction. Indications for emergency operation were a myocardial ischaemia time of less than 4 h and a slow flow in the reopened artery despite percutaneous transluminal coronary angioplasty. Two patients were in cardiogenic shock treated by inotropic drugs and intra-aortic balloon pump. In all cases, the level of fibrinogen was less than 1 g X l-1. During the operation, the fibrinolysis was stopped by the intravenous injection of aprotinine (3,000,000 U X 2) and tranexamic acid (15 mg X kg-1), the coagulation factors used by the fibrinolysis being replaced by fibrinogen (1 g per litre of blood volume) and fresh plasma (6 to 8 packs in function of the haemodynamic state). Patient heparinization was as usual (300 IU X kg-1). At the end of the cardiopulmonary bypass, after injection of protamine, clotting quality was good and the fibrinogen level was more than 1 g X l-1. In the postoperative period, blood loss was of little importance. Coagulation troubles due to therapeutic fibrinolysis were reversible. It was possible to return quickly the patient's coagulation state to normal, and so carry out emergency coronary arterial surgery in a defibrinated patient. The indications for surgery depended on cardiogenic factors only.

Performance of recipient hearts after heterotopic transplantation.

Twenty-two heterotopic heart transplantations were performed, in 19 of which the evolution of the recipient heart was estimated. Within the first postoperative hours the recipient heart was often more effective than the donor heart. The discrepant rhythm between the 2 hearts did not result in any pathological findings. The increased pressures in the recipient's right heart always decreased, sometimes within several weeks. The left atrial volume was found to be reduced while left ventricular contraction was sometimes unchanged, sometimes improved and in a few cases showed definite improvement with a mean decrease of the ultra-sound diastolic diameter of 20 mm on echocardiography. The technique of heterotopic systems seems to be a useful indication for end-stage cardiomyopathies with pulmonary hypertension (class IV) which is generally considered a contraindication for orthotopic heart transplantation.

[Anatomical and hemodynamic evolution at midpoint follow-up with the assisted heart in heterotopic heart transplantation. Apropos of 21 cases]. / Evolution anatomique et hémodynamique à moyen terme du coeur assisté dans la transplantation cardiaque hétérotopique. A propos of 21 observations.

Between November 1978 and March 1985, 27 cardiac transplant operations were performed at the Arnault Tzanck Institute; Barnard's heterotopic method was used in 21 cases. In 16 cases, follow-up was prolonged to assess the effects on the assisted receiving heart. In the first postoperative hours the receiving heart is often more effective than the graft. There were no pathological consequences due to the two different rhythms. The increased pressures in the right cavities of the receiving heart decreased but sometimes this look several weeks. The volume of the left atrium decreased. Left ventricular contraction was unchanged in some cases but in others it improved significantly. This was accompanied by an average decrease of 20 mm in echocardiographic left ventricular end diastolic internal dimension. This technique of heterotopic assistance seems particularly suitable for advanced stages of cardiomyopathy with stage IV pulmonary hypertension.

[Transluminal coronary angioplasty. Experience apropos of 155 procedures]. / L'angioplastie coronaire transluminale. Expérience à propos de 155 procédures.

The authors report their experience of transluminal coronary angioplasty (TCA) from February 1980 to November 1983. 140 patients underwent TCA and 155 procedures were performed. The mean age was 55 years (range 33 to 74 years). Clinically, the patients presented with Stage I angina in 26 cases (18 p. 100), Stage II in 18 cases (13 p. 100), Stage III in 24 cases (17 p. 100) and Stage IV in 72 cases (52 p. 100), according to the NYHA Classification. 23 patients (16.5 p. 100) underwent combined thrombolysis - TCA. The coronary artery disease was limited to a single vessel in 135 cases (96 p. 100) and involved 2 vessels in 5 cases (4 p. 100). The overall results showed a 71 p. 100 primary success rate. There were no fatalities. The incidence of myocardial infarction was 3 p. 100 (5 patients) and emergency coronary bypass surgery was necessary in 16 patients (10 p. 100). The results in two groups of patients were compared: Group A: 69 patients treated with a conventional balloon catheter. Group B: 86 patients treated with a balloon catheter with a guide wire. The coronary stenosis was catheterised in 73 p. 100 of patients in Group A, and 90 p. 100 of patients in Group B (p less than 0.01). The primary success rate was 56 p. 100 in Group A and 83 p. 100 in Group B. The use of this new material improves the primary success rate and also makes more distal, anatomically atypical lesions, accessible.