[Reversible graft dysfunction after cardiac transplantation]. / Dysfonction réversible du greffon après transplantation cardiaque.

The authors report 3 cases of major graft dysfunction after cardiac transplantation which recovered completely with biventricular mechanical assistance in 4 to 8 days. All three cases were primary biventricular graft failures in patients with normal preoperative pulmonary resistances. These early dysfunctions (with no signs of myocardial infarction on electro- or echocardiography and in the absence of abnormal increased peri-operative enzyme levels) associated with total functional recovery conforming to the definition of the phenomenon of myocardial stunning. These results argue in favour of aggressive management of primary graft dysfunction.

Mitral subvalvular apparatus: different functions of primary and secondary chordae.

BACKGROUND: The aim of this study was to compare the function of the primary chordae attached to the free edge with that of the secondary chordae attached to the ventricular surface of the anterior mitral leaflet. METHODS AND RESULTS: An isolated working pig heart model was used. Three groups of 7 hearts were compared: Group A was the control group with intact leaflets. In group B, the primary chordae of the anterior leaflet were sectioned and the secondary chordae were left intact before assembly of the working heart model. In group C, the secondary chordae were sectioned and the primary chordae left intact. In group B, atrial and ventricular pressure evidenced dramatic mitral regurgitation. Video monitoring showed significant prolapse of the free edge of the anterior leaflet. Acute mitral regurgitation accounted for the decrease in aortic flow rate to 30 mL/min, significantly lower than in the control group (P=.006). In group C, sectioning of the secondary chordae left a competent mitral valve together with good coaptation of the anterior and posterior leaflets shown by video monitoring. However, aortic flow was lower than in the control group (P=.007), and ultrasonomicrometry evidenced impaired function (P=.009). CONCLUSIONS: This study suggests that the primary and secondary chordae of the mitral subvalvular apparatus have different functions. The primary chordae of the anterior leaflet appeared to be more involved in mitral valve competence, whereas the secondary chordae appeared to be more involved in left ventricular geometry and function.

Defibrillation threshold and electrode configurations: an experimental study testing three configurations in twelve pigs.

OBJECTIVE: The choice between epicardial or subcutaneous patches remains unclear and depends essentially on the team's habits. This study tested how much an additional patch can decrease defibrillation threshold (DFT), and compared a Subcutaneous Array and an epicardial patch. Today most implantable automatic defibrillators have a transvenous endocardial configuration alone but when the DFT remains high an additional patch is necessary. EXPERIMENTAL DESIGN: Three different configurations were tested with biphasic shocks in 12 pigs: Endovenous lead (Endo), Endovenous lead + subcutaneous patch (Endo + SQ) and Endovenous lead + epicardial patch (Endo + Epi). For each animal DFTs were determined in a balanced random order for the 3 configurations. Ventricular fibrillation was induced by pacing (30 Hz, 8 V, for 5 seconds). DFT was accurately measured with the up/down procedure until 3 reversal of defibrillation success or failure occurred. DFTs (mean +/- SD) were extracted and compared using paired t test and analysis of variance. RESULTS: DFTs were 14.6 +/- 11.0 J for Endo and significantly decreased (p < 0.01) when an additional SQ (9.4 +/- 7.2 J) or epicardial patch (8.9 +/- 6.5 J) was added to endovenous lead, without significant difference between Endo + SC and Endo + Epi configurations. CONCLUSIONS: Regarding this important decrease of DFT (respectively -35% for Endo + SC and -39% for Endo + Epi), additional patches should be more often recommended in patients with low safety margin of DFT. In those cases subcutaneous patches should be preferred instead of epicardial patches. Moreover, an additional reason to recommend this attitude could be the possible generator batteries saving.

Outcome of atrial fibrillation after mitral valve repair.

OBJECTIVE: The aim of the study was to evaluate the prognostic factors for return to sinus rhythm after mitral valve repair. METHOD: One hundred ninety-one patients underwent surgery for mitral valve repair, including 142 procedures for valve repair only (74%). The patients with preoperative atrial fibrillation (50.5%) were older, clinically more symptomatic, and had a greater degree of left atrial dilation than the patients who had sinus rhythm. RESULTS: Preoperative cardiac rhythm, the duration of preoperative atrial fibrillation, and a lesser degree of left atrial hypertrophy are significant prognostic factors independent of the maintenance of sinus rhythm. The probability of return to stable sinus rhythm was 93.7% when sinus rhythm was already present before the operation and 80% when atrial fibrillation was intermittent or of less than 1 year's duration; probability declined abruptly for durations over 1 year. No significant difference in patient survival was noted between those who had sinus rhythm (99% +/- 0.9% at 1 year and 86% +/- 6.6% at 5 years) and those who had atrial fibrillation in the preoperative period (95% +/- 3.1% at 1 year and 86% +/- 8.4% at 5 years). In contrast, the postoperative return to sinus rhythm was associated with 99% +/- 0.9% and 94% +/- 4.8% survivals at 1 and 4 years versus 97% +/- 1.5% and 77% +/- 13% in the event of postoperative atrial fibrillation. CONCLUSION: The aim of restoring postoperative sinus rhythm after mitral valve repair should lead to surgery being conducted on patients who have sinus rhythm or recent-onset atrial fibrillation. Surgery for atrial fibrillation may be of value in patients with a long history of atrial fibrillation, providing that it does not induce prohibitive excess mortality.

Long-term follow-up of small (size 20 and 21) Medtronic-Hall aortic valve prostheses.

BACKGROUND: Our goal was to study the long-term follow-up of patients having aortic valve replacement and to focus particularly on the patients receiving small prostheses. METHODS: Four hundred twenty-eight Medtronic-Hall valves were implanted (156 size 20 or 21 mm, 149 size 22 or 23 mm, and 123 size 25 or 27 mm). Group 20-21 had a higher number of female patients, more associated coronary lesions, and more patients with aortic stenosis. RESULTS: The actuarial survival rate at 8 years was 80% for group 20-21, 80% for group 22-23, and 76% for group 25-27 (p = not significant). In group 20-21, the actuarial event-free rates at 8 years were as follows: thromboembolic complications, 94%; prosthetic valve endocarditis, 99%; reoperation, 98%; and hemorrhagic complications, 78%. The only factors of prognostic value in this group were age and associated coronary lesions. CONCLUSIONS: The durable nature of the results obtained with the Medtronic-Hall 20- and 21-mm prostheses compared with large-diameter prostheses allows the use of a simple and reliable surgical technique and should mean that indications for ring enlargement become rare.

Long conservation organs in heart transplantation: postoperative results and long-term follow-up in fourteen patients.

Between 1988 and 1995, 14 heart transplantations were performed after a long preservation period (10 to 13 hours). The transplantation procedure (Shumway) was standard, and our results were achieved through the implementation of a very strict reperfusion technique that included low pressure and low cardiopulmonary bypass output for the first 10 minutes. Three patients died during the postoperative period, and the survival rate was 75% at 1 year and 71% at 5 years. The results obtained with hearts stored for such long periods are comparable to the results obtained with hearts stored for less than 4 hours.

[Thoracic aortic aneurysm in Marfan syndrome]. / Anévrysme de l'aorte thoracique dans la maladie de Marfan.

Thoracic aortic aneurysms are the main cardiovascular complication of Marfan's syndrome. Elastic tissue dystrophy of the ascending aorta is responsible for appearances of cystic medial necrosis in the major forms. Dilatation of the ascending aorta is progressive with time. The risk of dissection and rupture, an acute complication of Marfan's syndrome, is very high when the aortic dilatation reaches 60 mm, although dissection may be observed with dilatation of 50 mm. Aortic regurgitation is found in half the cases. Echocardiography, CT scan and MRI provide accurate assessment of the anatomy of the lesions and help in following up the dilatation. Betablocker therapy slows down the progression of the dilatation. Bentall's procedure was first described in 1968 with its technical variants for reimplantation of the coronary arteries: Cabrol's procedure, technique of periostal lean-to, the button technique, are major advances in the surgical treatment of ascending aortic aneurysms. The life expectancy is reported to be about 90% at 5 years and 75 to 80% at 10 years. Reoperation is sometimes necessary because of pseudo-aneurysms occurring as a late complication at the operation site or because of other aneurysms developing. Progress in the field of genetics is a hope for the future.

Thoracoscopic approach to implantable cardioverter defibrillator patch electrode implantation.

Even if transvenous lead system for automatic implantable cardioverter defibrillators (ICDs) has been one of the main surgical advances in the recent past, its major limitation is the high defibrillation thresholds in some cases. Thus, an additional patch may be required and implanted either in a subcutaneous position or in an epicardial position. We describe another possibility: the implantation of extrapericardial patch under video-thoracoscopic control. This new technique allows a deep implantation of the whole material without thoracotomy. Seven patients were included in our preliminary experience. During defibrillation threshold evaluation, two patients required 34 J with the single transvenous lead system, and five patients were not defibrillated with the single lead system; therefore, they required a 300-J external rescue shock. We decided to implant an additional patch in those seven patients with high defibrillation thresholds. This patch was inserted into the pleural cavity through a left subcostal incision. Under video thoracoscopy, it was positioned and stitched onto the pericardium. The defibrillation generator was then implanted through the left subcostal incision in a subdiaphragmatic space. As a result, preoperative defibrillation thresholds were significantly reduced (14.29 +/- 3.45 J, mean +/- SD) and remained stable during follow-up controls (eighth day and second month). Long-term follow-up (14 +/- 4.5 months) was uneventful, with an excellent tolerance for the patients. In conclusion, extrapericardial implantation of defibrillation patches under video thoracoscopy is an easy technique that allows low defibrillation thresholds.

[Aneurysms of the left ventricle without atheromatous coronary artery disease. Apropos of 2 cases]. / Les anévrysmes du ventricule gauche sans lésions coronaires athéromateuses. A propos de deux observations.

Left ventricular aneurysms are usually secondary to myocardial infarction with atheromatous coronary artery disease. The authors report two rare cases of non-atheromatous left ventricular apical aneurysms. The first case was clearly post-traumatic but the diagnosis in the second case was more difficult. The authors discuss the aetiological diagnosis of these rare non-atheromatous aneurysms in adults and the therapeutic management with respect to these two cases and a review of the literature.

[Long-term development of aortic valve stenosis surgically treated at an advanced stage]. / Evolution à long-terme des rétrécissements aortiques opérés à un stade évolué.

From January 1972 to June 1990, 112 patients (39 to 83 years old), 67 males and 45 females were submitted to surgery for sever calcified aortic stenosis. 68 patients were in NYHA III (60.72%) and 44 in NYHA IV. Early mortality included 8 patients (7.14%), 6 died for cardiac reasons. Late mortality was 27.67%. Actuarial survival rate (including postoperative mortality) was 88.39%, 77.67%, 67.85% and 65.17% at one year, five, ten and fifteen years, respectively. Results were significantly correlated to left branch block on preoperative EKG, episodes of complete heart failure, significant coronary stenosis, the cardioplegia technique and the association with coronary bypass.

Valvular replacement for aortic stenosis on patients in NYHA class III and IV. Early and long term results.

From January 1972 to June 1990, 112 patients between 39 and 83 years old, divided into 68 NYHA class III (60.72%) and 44 NYHA class IV, underwent surgery for aortic stenosis. There were 67 male (59.82%) and 45 female (40.18%). Early mortality included 8 patients (7.14%). Actuarial survival (including early postoperative mortality) for all 112 patients was 88.39%, 77.67%, 67.85% and 65.7% t one year, five, ten and fifteen years respectively. Clinical criteria are subjective but they remain the best prognostic factor. Surgery is indicated at occurrence of first symptoms, but, even in advanced cases, aortic valvular replacement can significantly improve survival and functional status. Even if operative risk is increased and secondary cardiomyopathy often progresses after surgery, aortic valve replacement results seem better than those of medical treatment alone.

Subdiaphragmatic implantation of implantable cardioverter defibrillator generator.

Despite several improvements in the surgical technique and in the technologic design of cardioverter defibrillators made over the past years, abdominal placement of the generator device, done as Mirowski did it in his first implantation performed in 1980, remains the widely used method. Although smaller defibrillators are available, they remain bulky and are a source of local complications. To prevent such complications and to enhance patient comfort, we performed a subdiaphragmatic implantation in 31 patients.

[Post-infarction rupture of the heart into the pericardium. Surgical treatment combining synthetic patch and biological fibrin glue]. / Rupture du coeur post-infarctus en péricarde libre. Traitement chirurgical associant patch synthétique et colle biologique à base de fibrine.

A 66-year old man was hospitalized with chest pain and acute ischaemia of the lower limbs highly suggestive of dissection of the aorta. Computed tomography and aortography however showed pericardic effusion and thrombosis situated in the iliac bifurcation of the aorta. During the emergency operation, acute tamponade required sub-xyphoid drainage. The haemodynamic situation was reestablished and the operation continued but within minutes a cataclysmal haemorrhage occurred through the drainage tube due to ischaemic rupture of the lateral wall of the heart into the pericardium. Extra-corporal circulation was installed immediately and a large polytetrafluoroethylene patch was sutured to the epicardium, distally from the necrosed area, in healthy tissue. A biological fibrin glue was injected under the patch. The operation was terminated with an axillo-bifemoral bypass. The postoperative period was satisfactory and the patient was discharged. At the six months examination, the patient was in NYHA class II and the echography showed moderate left ventricular dysfunction with grade II mitral regurgitation and a false aneurysm facing the area of necrosis. This technique allowed us to patch the rupture without excessive tension on the sutures in the fragile tissue which would have increased the risk of secondary rupture. In addition, the large patch avoided excessive reduction in volume of the left ventricular cavity and saved the mitral chordae which would have been destroyed by direct suture. This method can be an effective salvage technique for heart rupture during the acute phase of myocardial infarction and offers the possibility of a second look in case of a secondary false aneurysm.

[Automatic implantable defibrillators; subdiaphragmatic insertion]. / Défibrillateur automatique implantable; mise en place sous-diaphragmatique du boîtier.

Although the material and techniques of implantation of the electrodes of implantable defibrillators have been improved, the abdominal implantation of the generator remains widely used as described by Mirowski in 1980. Despite a progressive reduction in their size, the generators remain bulky and a source of local complications. The risks and discomfort of implantation in the abdominal wall led the authors to try subdiaphragmatic implantation in 22 patients. There was no morbidity with perfect healing in all 22 cases. The mean follow-up period was 11 months. The patients felt very comfortable, a significant advance with respect to abdominal implantations.

[New approach for implantation of automatic defibrillators using videothoracoscopy]. / Nouvelle approche pour l'implantation des défibrillateurs automatiques utilisant la vidéo-thoracoscopie.

Nonthoracotomy lead systems are increasingly used in patients (pts) with implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibrillation threshold (DT) may persist leading to thoracotomy for epicardial patch placement. In a preliminary experience, 3 patients with high DT (> 20 J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, sutured and connected to the defibrillator. DTs were 10, 10 and 20 J respectively in our 3 patients. Postoperative course was uneventful. Thoracoscopy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrillation was achieved with the same minimal energy levels used peroperatively. In conclusion, extrapericardial patch insertion using thoracoscopy may help reduce DT in ICD patients with a non thoracotomy lead system. Comparison with other lead configurations requires further investigation.

[Implantation of automatic defibrillators by means of video-thoracoscopy. Authors' experience]. / L'impianto dei defibrillatori automatici mediante video-toracoscopia. La nostra esperienza.

The implantable cardioverter-defibrillator represents an effective option for some potentially lethal ventricular arrhythmias. Nowadays defibrillation electrodes are often endoluminal only. In some patients, however, the presence of high defibrillation thresholds mandates the implantation of a subcutaneous patch. If the subcutaneous patch does not allow a sufficient decrease in defibrillation threshold, then two epicardial patches are generally implanted by different surgical approaches. Nevertheless surgical trauma could be a serious hazard in unstable patients. In 6 patients in whom endoluminal electrodes did not allow a safe defibrillation threshold, an extrapericardial patch has been implanted by means of a video-thoracoscopic approach: a left subcostal incision is performed and the subdiaphragmatic extraperitoneal space is reached; a patch electrode is then introduced into the left pleural cavity by blunt dissection of the diaphragm. This patch is positioned under thoracoscopic control in contact to the left pericardial surface and fixed by single stitches sutures. The impulse generator is finally implanted into the subdiaphragmatic pocket. In all the patients the patch electrode configuration sufficiently decreased defibrillation thresholds. In one of the patients a stellectomy was thoracoscopically performed to treat the long QT syndrome which was the cause of the ventricular fibrillation episodes. Defibrillation thresholds were confirmed after 8 day and 2 months postoperatively. In conclusion, the thoracoscopic implantation of an extrapericardial patch has allowed a significant reduction of defibrillation thresholds, without recurring to a major surgical procedure.