[The role of the urology nurse in prehabilitation and same-day discharge robot-assited radical prostatectomy programs]. / Le rôle de l'IDE dans l'éducation thérapeutique avant opération et la mise en place d'un programme de prostatectomie totale robotique en ambulatoire.

INTRODUCTION: The purpose of this article is to explain the role of urology nurse in prehabilitation and same-day discharge programs for robotic radical prostatectomy. METHODS: This article is based on the analysis of the literature and the experience of our center. RESULTS: In order to prepare patients for outpatient surgery, urology nurse plays a key role during prehabilitation journeys. Two weeks before the operation, the healthcare teams (nurses, anesthetists, physiotherapists, etc.) organize workshops to explain to patients the operation course and post-operative care in order to allay any anxieties. Individual and group interviews, in specific workshops (compression stockings, urinary catheter, sexology) are organized in particular with urology nurse to answer all patients' questions. In association with enhanced recovery after surgery pathway, these programs improve the patient experience and satisfaction as well as peri-operative outcomes, and allows the development of an outpatient surgery program which currently represents approximately one third of surgeries. CONCLUSION: The implementation of perioperative protocols including prehabilitation improves the early results of robotic total prostatectomy, but also the patient experience. The urology nurse has a key role to play during these patient education days and in the preparation, information, support and follow-up of the patient, since the prehabilitation journey until the patient leaves the outpatient clinic.

[Isolated prolapse of the posterior leaflet of the mitral valve. Results of reconstructive surgery]. / Prolapsus isolé du feuillet postérieur de la valve mitrale. Résultats de la chirurgie reconstructrice.

Out of 522 patients undergoing mitral valve reconstruction for mitral regurgitation between 1988 and June 1994, the authors studied 159 cases of isolated mitral regurgitation by prolapse of the posterior mitral leaflet. There were 98 men (62%) and 61 women (38%), with an average age of 58.4 +/- 10.4 years. The functional class and ejection fraction were 2.8 +/- 0.11 and 0.66 +/- 0.2 respectively. In 155 patients, surgery consisted in quadrangular resection of the prolapsed tissue, followed in 83 cases by sliding posterior valvuloplasty and in 72 cases by plicature of the annulus. In 4 cases, the prolapse was treated by implantation of artificial chordae tendinae. A Carpentier-Edwards ring was inserted in all cases. There were no hospital deaths. Echocardiography was performed before discharge from hospital and showed satisfactory mitral valve function in 98% of cases: slight systolic anterior motion (SAM) was observed in one case. All patients were followed up for an average of 3.67 +/- 0.10 years. At six years, survival was 93 +/- 7%; moreover, 93 +/- 7% and 97 +/- 3% of patients had no thromboembolic or haemorrhagic complications. Six patients were reoperated, three of them in the first year of follow-up. At six years, 95 +/- 5% of patients were free of reoperation and 81 +/- 11% were free of all complications. The authors conclude that the excellent medium term survival and the low rate of complications are evidence in favour of conservative surgery for treatment of mitral regurgitation due to prolapse of the posterior mitral leaflet.

Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet.

BACKGROUND: Although prolapse of the posterior leaflet is the most common abnormality of the mitral valve causing dysfunction, the long-term results of mitral valve repair for this condition are seldom reported. METHODS: From October 1988 to June 1994, 208 patients (mean age, 59.4 years) with mitral regurgitation caused by isolated prolapse of the posterior leaflet underwent mitral valve repair alone or combined with myocardial revascularization (n = 30). The surgical techniques were quadrangular resection (n = 199) followed by annulus plication (n = 101) or sliding leaflet plasty (n = 98), use of artificial chordae (n = 5), or papillary muscle shortening (n = 4). All patients had an annuloplasty with a Carpentier ring. Mean follow-up was 3.4 +/- 0.1 years and total follow-up, 656 patient-years. RESULTS: There were six operative deaths (2.9%). Postoperative Doppler echocardiography found two cases of systolic anterior motion (1%), and echocardiographic studies at follow-up showed satisfactory mitral valve function in 97% of 112 patients. At 6 years, the actuarial survival rate was 87% +/- 7%, and freedom from thromboembolic complications, bleeding complications, and reoperation was 93% +/- 7%, 95% +/- 3%, and 95% +/- 4%, respectively. CONCLUSIONS: Mitral valve repair for regurgitation caused by prolapse of the posterior leaflet provides excellent survival at 6 years and should be considered the method of choice for its surgical treatment.

[Löffler's parietal fibroplastic endocarditis. Echocardiographic course over 5 years]. / Endocarditis parietalis fibroplastica Löffler. Echokardiographischer Verlauf über 5 Jahre.

HISTORY AND CLINICAL FINDINGS: A 28-year-old man, who had sustained a traumatic displaced fracture of the left lateral clavicle requiring operative realignment, was admitted to hospital because of the incidental finding of pathological electrocardiographic findings (suggestive of past anterior myocardial infarction). He had dyspnoea on effort and episodes of irregular tachycardia without other cardiac symptoms, as well as regular tachycardia (120/min) without pulse deficit. Body temperature was 37.3 degrees C, blood pressure 110/70 mm Hg. INVESTIGATIONS: Transoesophageal echocardiography showed regular myocardial contractility but a 3.27 cm cap-like area of echo-poor and echo-dense layers at the left ventricular apex. There was leucocytosis (25,400/microliter) with 45% eosinophilia (11,430/microliter). IgE was raised to 134.6 kU/l. Bone marrow smear showed marked eosinophilic but little neutrophilic hyperplasia. Parasitic infection was excluded. TREATMENT AND COURSE: The clinical and echocardiographic findings suggested the diagnosis of Löffler's eosinophilic endocarditis (endomyocardial fibrosis), later confirmed histologically. After initial treatment, first only with cortisone then also hydroxyurea, the eosinophilia finally responded to combined cortisone and interferon alpha 2. The dosage schedule was governed by the clinical and echocardiographic findings. In the further course of the disease there occurred progressive heart failure with severe tricuspid and mitral regurgitation, secondary pulmonary hypertension and severe fibrosis of both ventricles, 41 months after diagnosis the patient underwent tricuspid and mitral valve reconstruction with removal of the endocardial fibrotic layers. Follow-up examinations found the cardiac condition to be adequately controlled without further cardiac infiltration since 20 months. CONCLUSIONS: Echocardiography, in conjunction with the clinical findings, provides a firm foundation for successfully treating Löffler's endocarditis. In selected cases cardiac surgery can markedly improve the course.

[Clinical experiences with mitral valve reconstruction]. / Klinische Erfahrungen mit der Mitralklappenrekonstruktion.

Between October 1988 and December 1993, 433 patients with mitral valve insufficiency underwent mitral valve repair. Patient's age ranged from 13 to 82 years (mean age 59.5 years). Mitral valve insufficiency was due to degenerative disease in 192 patients (44%), ischemic disease in 102 (23%), rheumatic disease in 76 (18%) and other causes in 63 patients (15%). Most of the patients (337) were in functional class III or IV. The patients were divided into 3 functional groups: type I (normal leaflet motion) 141 patients (33%), type II (leaflet prolapse) 265 patients (61%) and type III (restricted leaflet motion) 27 patients (6%). Two patients were lost to follow-up for a total follow-up of 761 patients per year. The operative mortality was 2.5% for the total group, 0.4% for the group with isolated mitral valve insufficiency, 7.5% for the group with mitral valve repair associated with coronary artery bypass grafting and 2.9% for the group associated with tricuspid valve repair. At the time of the discharge, 71% of the patient at Doppler echocardiography showed no mitral regurgitation, 25.5%, 3% and 0.5% showed a mitral regurgitation grade 1,2 or 3 respectively. The 5-year actuarial survival was 84%. At 5 years, 96% of the patients were free from reoperation, 96% free from thromboembolism and 93% free from bleeding complications. Among the survivors 93% of the patients were in functional class I or II.

Isolated cleft mitral valve: valve reconstruction techniques.

Reports concerning an isolated cleft of the anterior mitral valve are rare. This congenital anomaly of the mitral valve is usually repaired by suturing the edges of the cleft. We report 4 cases of isolated anterior mitral cleft. The patients ranged in age from 13 to 41 years. The clinical symptoms were those typical of mitral insufficiency. In all 4 patients, preoperative echocardiography was able to establish the exact anatomic diagnosis. In 1 patient, the cleft was directly sutured, whereas, in the other 3 patients, a fibrous reaction of the edges of the cleft with a subsequent lack of valvular tissue made direct suture technically impossible. Instead, the fibrous edges of the cleft were resected and the anterior leaflet of the mitral valve was reconstructed using an autologous pericardial patch pretreated with buffered glutaraldehyde. All 4 patients underwent annuloplasty together with placement of a Carpentier mitral ring. Postoperative echocardiograms have confirmed good results of the repair; 1 patient has a trivial insufficiency and 3 have a completely competent mitral valve.

Septal myectomy for left ventricular outflow tract obstruction after mitral valve repair.

We describe a patient with a left ventricular outflow tract obstruction after mitral valve repair. Intraoperative transesophageal echocardiography permitted us to recognize the role of a bulging septum in the development of a systolic motion of the mitral valve. A left ventricular septal myectomy and myotomy was able to relieve the left ventricular outflow tract obstruction and the systolic anterior motion of the mitral valve.

Carpentier "sliding leaflet" technique for repair of the mitral valve: early results.

Reconstructive mitral valve operation is now the preferred technique for the surgical treatment of prolapse of the posterior leaflet due to degenerative disease. Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction has been observed after such repair, with an incidence ranging from 4.5% to 10%. In an attempt to reduce the incidence of this complication, Carpentier has devised a new technique: the sliding leaflet plasty of the posterior leaflet. We report on 48 patients who underwent this new procedure between July 1990 and July 1992. One patient died perioperatively (2.1%). All other patients were able to be discharged on the ninth postoperative day. All patients underwent M-mode, two-dimensional, and Doppler echocardiography before discharge. Forty-one patients (85%) had no evidence of postoperative regurgitation, whereas 7 patients (15%) showed mild mitral valve insufficiency. Left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve was never detected. We believe that this technique of mitral valve repair is safe and seems to be effective in achieving a decreased incidence of left ventricular outflow tract obstruction.

[Double mitral orifice. Apropos of a case]. / Double orifice mitral. A propos d'une observation.

The authors report a case of Double Mitral Orifice (DMO), existing in isolation and type 3 by the Floch Prigent classification. This rare anomaly is often associated with another congenital malformation, dominated by intra-atrio-ventricular defect. Two-dimensional echocardiography is the essential diagnostic factor. Hemodynamic consequences may be nil, but mitral insufficiency and/or stenosis may complicate this malformation. Treatment may be summarised as abstention, surgical repair or valve replacement, according to the severity of lesions.

Long-term evaluation of the Carpentier-Edwards pericardial valve in the aortic position.

From July 1980 to December 1985, 124 patients underwent isolated aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis. The mean age of the patients was 64.9 +/- 13.1 years. All patients but one (0.7%) were followed for an average of 5.52 +/- 0.21 years after the operation and follow-up totaled to 677 patient-years. There were six early deaths (30-day mortality of 4.8%) and 25 late deaths (3.7% +/- 0.7% patient-year). After 9 years the actuarial survival rate was 64% +/- 14%. Six patients died of valve-related deaths (three anticoagulant-related hemorrhage, one endocarditis, one thromboembolic complication, and one sudden death) for an actuarial rate of 95% +/- 5% patients free of valve-related death at 9 years. Valve-related complications included five thromboembolic episodes (0.7% +/- 0.3% patient-year), eight anticoagulant-related hemorrhagic complications (1.2% +/- 0.4% patient-year), and two reoperations (0.3% +/- 0.2% patient-year). After 9 years, freedom from thromboembolic events was 96% +/- 4%, that from anticoagulant-related hemorrhage was 93% +/- 5%, and that from reoperation was 98% +/- 2%. There was no structural deterioration of the valve. We conclude that the Carpentier-Edwards pericardial prosthesis has a low incidence of valve-related complication and mortality within the 9-year time frame of this study.

Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair.

Preliminary experimental studies in our laboratory have shown that autologous pericardium treated with glutaraldehyde prevents late deterioration and calcification of the tissue. For this reason, glutaraldehyde-treated autologous pericardium has been used in a series of 64 patients who underwent operations for leaflet extension of the mitral valve between 1980 and 1989. Ages ranged from 2.5 to 60 years (mean 19 +/- 15). The causes of mitral valve insufficiency were rheumatic fever (69%), bacterial endocarditis (17%), congenital (8%), endomyocardial fibrosis (4.5%), and trauma (1.5%). The autologous tissue was fixed in a 0.62% glutaraldehyde solution for 15 minutes and rinsed in saline for an additional 15 minutes. Patching techniques varied depending on the site and the extent of the lesion. Associated mitral valve repair techniques (Carpentier's techniques) were mandatory in all patients. The period of follow-up extended from 6 months to 9 years (mean 3.1 +/- 2.5 years). There were no operative deaths in this series, and there was one late death (2%). In the six patients (12%) who underwent reoperation, there has been no case of calcification of the pericardial patch. Postoperative mitral valve function was assessed by bidimensional color Doppler echocardiographic techniques. Mitral valve insufficiency was trivial or absent in 80% of the patients. This experience permits us to conclude that leaflet extension is a simple and safe technique in valve reconstruction, allowing repair of mitral valves that otherwise would need to be replaced. It permits use of an adult-size prosthetic ring in children. Glutaraldehyde-treated autologous pericardium is the material of choice for this type of repair.

Mitral valve repair in the extensively calcified mitral valve annulus.

Mitral valve replacement in patients with an extensively calcified mitral annulus is associated with an increased risk of ventricular rupture. Until now techniques of mitral valve repair have not been applied to patients with a heavily calcified mitral valve annulus. We present 12 patients who underwent extensive decalcification of the annulus with subsequent mitral valve repair between 1987 and 1990. Ages ranged from 11 to 78 years; 6 patients were in New York Heart Association functional class II, 4 were in class III, and 2 were in class IV. All patients had varying degrees of mitral insufficiency. There were no deaths, reoperations, or thromboembolic events. Postoperative echocardiography revealed minimal residual mitral insufficiency in only 2 of 12 patients. All patients are currently in New York Heart Association class I or II. We believe mitral valve repair can be done safely on patients with an extensively calcified mitral annulus, thus avoiding the risks of left ventricular rupture, thromboembolic events, and hemorrhagic complications associated with mitral valve replacement.

Intra-operative transoesophageal echocardiography after mitral repair--specific conditions and pitfalls.

The aim of this study was to determine the specific conditions and pitfalls of immediate assessment of the reconstructed mitral valve in open chest patients. Sixty-two patients had a mitral reconstruction controlled by transoesophageal echocardiography and colour Doppler (TEE) from the moment when cardiac activity restarted under extracorporeal circulation (ECC), until complete rewarming of the patient and weaning off the by-pass. The following conditions altered the imaging quality: (1) dried probe in the oesophagus or air bubbles, (2) non-aspirated air from the stomach, (3) small or empty left atria, (4) invagination of the left atrial appendage, (5) trapped air in the posterior pericardium, (6) spontaneous contrast. Transient mitral regurgitation disappeared completely in 12/62 patients: five had temporary impairment of LV function, two had reduced filling of the heart, one had left ventricular outflow obstruction exacerbated by isoproterenol and nitroglycerin, two had ventricular ectopic rhythms, and two epicardial pacing. Only one of the 62 patients had persistent significant MR which required a second run of ECC. We conclude that mitral regurgitation after mitral valve repair is closely related to the quality of LV function. A decision to reoperate should eliminate the possible pitfalls, and take into consideration the specific conditions of immediate postoperative cardiac function.

[Demonstration of abnormalities of myocardial mitochondrial oxygenation in cardiac graft rejection]. / Mise en évidence d'anomalies de l'oxydation mitochondriale myocardique au cours du rejet de greffe cardiaque.

Abnormalities of myocardial metabolism during acute rejection may be due to ischemia to primary metabolic changes related to rejection. An experimental study of heterotopic cardiac transplantation in the rat was undertaken to study myocardial mitochondrial oxidation during acute rejection. The receivers were Lewis rats and the donors Fischer (FL: allograft) or Lewis (LL: isograft) rats. The oxygen consumption of the mitochondria (VO2m) isolated from the transplanted and native hearts was measured by oxygraphy six days after transplantation. Using maleate and glutamate substrates, the VO2m of transplanted hearts was significantly lower than that of native hearts in the two groups of rats (FL, p less than 0.01; LL, p less than 0.01). In addition, the VO2m of FL allograft transplanted hearts was significantly lower than in the LL rats (30 +/- 9 vs 100 +/- 15 nanoatoms of oxygen/min.mg/prot, p less than 0.01) as was the VO2m of the native hearts (FL: 106 +/- 23 vs LL: 164 +/- 26, p less than 0.02). The respiratory control ratio (RCR) was significantly lower in the transplanted than in the native hearts in both the FL and LL groups (p less than 0.05 and p less than 0.01 respectively). The comparison of the RCR in the two groups (FL vs LL) showed no significant difference for transplanted or native hearts. Electron microscopy of transplanted (rejected or not) and native hearts showed no morphological abnormality of the mitochondria. The lower VO2m of the allograft group indicates a disturbance in the mitochondrial respiratory pathway during acute rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Failures in reconstructive mitral valve surgery.

From 1969 to 1985, mitral valve repairs using Carpentier's technique were performed for acquired mitral valve incompetence. 72 patients required a reoperation 3 days to 13 years later (mean 5 +/- 3.5 years). The reoperation rate risk was dependent upon the etiology: Barlow 0.6 +/- 0.2% patient year, fibro-elastic deficiency 0.7 +/- 0.3, endocarditis 1.7% Rheumatic disease 4.6 +/- 1.4%. The risk of reoperation in Rheumatic disease is significantly higher (p less than 0.05) than in degenerative disease. The causes of failures could be categorized into two groups according to whether they are surgeon related or valve related: Group I, Prosthetic ring dehiscence or malposition 15%, anulus dilatation (when no ring was implanted) 4%, triangular resection of the anterior leaflet 4% residual prolapse 8.3%. Group II, Recurrent prolapse 16.6% valve stenosis 17%, leaflet retraction 35%. Failures in Group I can be reduced with "increased" experience as opposed to group II. At reoperation valve repair was possible in 15.3% of the cases whereas valve replacement was necessary in 84.7% with an overall operative mortality of 1.4%. We conclude that mitral valve repair in acquired mitral incompetence carries out a small risk of reoperation. Most of the repair failures are surgeon related in degenerative disease and valve related in rheumatic disease.

Valve repair with Carpentier techniques. The second decade.

Among 206 consecutive patients having undergone mitral valve repair with a prosthetic ring between 1972 and 1979 in our institution, the 195 patients (94.5%) who survived the operation were studied to assess the long-term function of this method of repair. Patients' ages ranged from 18 to 79 years (mean age 48.7 years). Mitral valve insufficiency was due to degenerative disease in 113 patients (58%), rheumatic disease in 74 (38%), ischemia and other causes in eight patients (4%). A total of 188 patients (9.7%) were in New York Heart Association class III or IV preoperatively and 94 (48%) had atrial fibrillation. The patients were divided into three functional groups: type I (normal leaflet motion), 35 patients (18%); type II (leaflet prolapse), 147 patients (75%); and type III (restricted leaflet motion), 13 patients (7%). The techniques included prosthetic ring annuloplasty (185 patients), leaflet resection (158 patients), chordal shortening (89 patients), leaflet mobilization (10 patients) and papillary muscle reimplantation (2 patients). Long-term follow-up was available in 189 patients (96.8%), for a rate of 2316 patients per year. The 15-year actuarial and valve-related survival rates were 72.4% and 82.8%, respectively. At 15 years, 93.9% of the patients were free from thromboembolism, 96.6% free from endocarditis, 95.6% free from anticoagulant-related hemorrhage, and 87.38% free from reoperation. Actuarial rate of freedom from reoperation was higher in the group with degenerative disease (92.7%) than in the group with rheumatic disease (76.12%). Among the 157 survivors, 117 (74%) were in New York Heart Association class I and class II and 105 (66%) were in sinus rhythm. Doppler echocardiographic studies showed normal ventricular contractility in 134 patients (84.5%), absence of mitral regurgitation in 112 (74%), trivial regurgitation in 27 (17%), and significant regurgitation in 4 patients (2.5%).

Cardiac assistance by atrial or ventricular cardiomyoplasty.

Dynamic cardiomyoplasty was conceived to enhance cardiac performance by assisting myocardial contraction. Technically, this procedure consists of placing a pedicled latissimus dorsi muscle flap around the heart and subsequent muscle electrostimulation in synchrony with ventricular systole. Three types of dynamic cardiomyoplasty can be considered. (1) Atrial or ventricular reinforcement is accomplished by wrapping the latissimus dorsi muscle flap around the heart to support hypokinetic or akinetic areas secondary to congenital or acquired diseases. The atrial reinforcement may be performed to improve atrial output after Fontan-type procedures. (2) Ventricular substitution is performed to replace a portion of the ventricular wall. Autologous pericardium is used to create a neoendocardium and facilitate hemostatic closure of the ventricle. The pedicled latissimus dorsi is then secured to replace the resected myocardium. (3) The two previous techniques of ventricular substitution and reinforcement are combined. This reconstructive procedure, which normalizes the ventricular geometrical shape, is particularly useful after extended cardiac resections, such as is done in treatment of large ventricular aneurysms, cardiac tumors, or echinococcal cyst formations. At present, improvement in ventricular function has been obtained in 12 patients at our institution. Preoperative severe cardiac dysfunction was present in all of these patients (New York Heart Association functional class III or IV). Postoperative echocardiography, multigated acquisition scan, and hemodynamic studies demonstrate an improvement in ventricular function and no impairment of ventricular compliance by the muscle flap. After a mean follow-up period of 18 months, all patients are in functional class I or II. We believe that dynamic cardiomyoplasty prolongs and improves the quality of life of patients suffering from severe chronic and irreversible myocardial dysfunction by improving ventricular contraction and limiting cardiac dilatation.

Cellular electrophysiological effects of flecainide on human atrial fibres.

STUDY OBJECTIVE: The aim of the study was to examine the electrophysiological characteristics of human atrial specimens collected during heart surgery and to investigate the effects of the class I antiarrhythmic agent flecainide on their electrical activity. DESIGN: Atrial specimens were studied using standard microelectrode techniques, with and without superfused flecainide (5 x 10(-7) M) or the transient outward current inhibitor 4-aminopyridine (0.5 mM). EXPERIMENTAL MATERIAL: Atrial fragments 0.5-1.0 cm2 were obtained at operation from 34 patients, mean age 30 years. There was no history of previous atrial arrhythmia in any patient and drug therapy was stopped 24 h before surgery. MEASUREMENTS AND MAIN RESULTS: Two types of transmembrane action potential were identified: (1) triangular shaped potentials (group A, classically found in animal models); (2) potentials with a large plateau preceded by a notch (group B). The effect of flecainide was compared on the the two types of action potential. In both, flecainide lessened the depolarisation rate. In group B, but not in group A, it increased the action potential duration at 50% and 90% repolarisation (APD50, APD90) and the effective refractory period. The notch in group B action potentials is generated by transient outward currents (Ito). Inhibition of these currents, either by increasing the pacing rate or by adding 4-aminopyridine, limited the increase in APD50, APD90, and effective refractory period generated by the presence of flecainide. CONCLUSIONS: The effects of flecainide on the atrial repolarisation process depend on the shape of the action potential. These effects are more marked in cells with a plateau, where Ito is activated.