[Cardiac surgery in Cameroon. Results at one year of the pilot phase]. / Chirurgie cardiaque au Cameroun. Résultats à un an de la phase pilote.

In the framework of implementation of his national program for control and prevention of cardiovascular diseases, Cameroonian government has set up a cardiac surgery project. We report in this manuscript results of one year follow up of the patients operated during the pilot phase. From September 22 till 26, 2008, 11 patients have been operated in Cameroun. Surgical procedures were 5 mitral mechanic valve replacement, 2 aortic mechanic valve replacement, 1 atrial septal defect closure, 2 pace maker implantation. No intrahospital death was observed. One patient died at 11th month after the operation due to mitral valve thrombosis and attributed to lack of compliance. One patient presented low cardiac output, pneumonia and a pleural effusion. 2 patients presented 2 minor complications consisting of pericarditis and superficial wound infection. The results of the pilot phase of cardiac surgery in Cameroon are effective. However, the sustainability of the program require human, material capacity building, and funding mechanism as well.

Closed chest coronary surgery. State of the art.

The so-called robotic systems have opened the era of closed-chest coronary surgery. We report the current status of the ongoing worldwide experience in the literature as the background of the present paper and address specifically some of the controversial aspects that are generated by this major paradigm shift which is introduced in the operating room. In conclusion we believe that, even though it is difficult to demonstrate incremental added value to a well established procedure such as coronary artery bypass graft (CABG), reducing the complications and cost of surgery accompany the implementation of the tools of new technologies. The added value of robotics to the therapeutic armamentarium in the treatment of coronary artery disease (CAD) may be worth the effort required for procedural development and the establishment of the learning curves. Only a thorough collection and presentation of the data from the early days will eventually demonstrate this added value for the patient and for the community before this technology spreads widely.

Conversion from ministernotomy to full sternotomy in aortic valve replacement.

Conversion (C) from ministernotomy (M.S.) to full sternotomy was necessary in 5% of the cases in a series of 100 patients consecutively operated for Aortic Valve Replacement (A.V.R.) Analysis of the demographics and surgical techniques indicate older age, aortic fragility, diffuse coronary disease, chronic renal failure and left vent insertion as contributing factors. Despite increased operative blood losses, extra-corporeal circulation (E.C.C.) times, intensive care unit (I.C.U.) stay and hospital stay, no mortality was observed in the conversion group, as compared to 4.2% mortality in the total ministernotomy (MS) population. Preoperative patients selection, avoidance of technical pitfalls, and knowledge of alternative surgical measures are suggested to further decrease the incidence of conversions.

[The heart surgery department]. / Le Service de Chirurgie Cardiaque.

The initial development of cardiac surgery at Erasme Hospital was closely related to the achievements in thoracic organ transplantation, with numerous synergies between other clinical and research units of the Faculty of Medicine. New advances in biology and biotechnology have met the challenges of modern cardiology, in the fields of advanced heart failure, refractory angina, rhythm disturbances or minimally invasive surgery. Fundamental aspects of clinical practice have been the subject of laboratory investigations, resulting in fruitful interactions and promising scientific outlooks.

Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting.

OBJECTIVE: Percutaneous transluminal coronary angioplasty (PTCA) or surgery can be chosen as first-line therapies in multiple-vessel coronary disease. A mammary-to-left anterior descending (LAD) graft is the most important statistical determinant of a favorable outcome after coronary artery bypass grafting (CABG) and can be performed with lower morbidity off pump through a minithoracotomy. PTCA and stenting of the "non-LAD" vessels compete with CABG in terms of patency rates. Our purpose was to compare a combination of minimally invasive direct coronary artery bypass (MIDCAB) and PTCA with double CABG as a treatment for double-vessel coronary artery disease involving the proximal LAD. METHODS: Two matched groups of 20 patients with double-vessel coronary disease undergoing either sequential MIDCAB and PTCA (group 1) or double CABG on cardiopulmonary bypass (group 2) were compared. Angiographic control, complications, hospital costs, quality of life, and 2-year follow-up of ischemia are reported. RESULTS: All bypasses were patent at early control. Three adverse events were noted in group 1 and 17 in group 2. The hybrid-procedure group exhibited a shorter intensive care unit stay, fewer blood products transfused, less pain, better early quality of life, faster return to work, and similar cost. Three patients required a second PTCA in group 1, one of which for restenosis. At 2 years all the patients are asymptomatic with no residual ischemia. CONCLUSIONS: We conclude from this pilot study that the hybrid procedure is feasible and appears to be a safe therapy for double-vessel coronary artery disease and that it appears to generate less perioperative morbidity than classic double CABG does. Therefore we believe that there is room to undertake prospective randomized studies on a larger-scale basis.

[Minimally invasive coronary bypass: experience at the Erasme Hospital in 1997-1998]. / Pontages coronaires moins invasifs: expérience à l'Hôpital Erasme en 1997-1998.

Since the launching of cardiopulmonary bypass in 1952 the landscape of cardiac surgery has been marked by a major milestone every ten years. Though most of the cardiopathies can be surgically treated with satisfactory results in up to 90% of the cases, we must try to improve the existing results. That means--Can we do better, cheaper and less invasive? Several new surgical approaches aiming at so doing are discussed in the present report: Minimally invasive direct coronary arterial bypass (MIDCAB) which is performed through a small anterior thoracotomy; Beating heart revascularization through sternotomy; Heart Port approach; Trans Myocardial Laser Revascularization (TMLR). Those new technologies respectively offer specific advantages to the existing therapies thus represent promising alternatives in selected subcategories of patients.

Effects of pulmonary embolism on pulmonary vascular impedance in dogs and minipigs.

Pigs have been reported to present with a stronger pulmonary vascular reactivity than many other species, including dogs. We investigated the pulmonary vascular impedance response to autologous blood clot embolic pulmonary hypertension in anesthetized and ventilated minipigs (n = 6) and dogs (n = 6). Before embolization, minipigs, compared with dogs, presented with higher mean pulmonary arterial pressure (Ppa; by an average of 9 mmHg), a steeper slope of Ppa-flow (Q) relationships, and higher 0-Hz impedance (Z0) and first-harmonic impedance (Z1), without significant differences in characteristic impedance (Zc), and a lower ratio of pulsatile hydraulic power to total hydraulic power. Embolic pulmonary hypertension (mean Ppa: 40-55 mmHg) was associated with increased Z0 and Z1 in both species, but the minipigs had a steeper slope of Ppa/Q plots and an increased Zc. At identical Q and Ppa, minipigs still presented with higher Z1 and Zc and a lower ratio of pulsatile hydraulic power to total hydraulic power. The energy transmission ratio, defined as the hydraulic power in the measured waves divided by the hydraulic power in the forward waves, was better preserved after embolism in minipigs. No differences in wave reflection indexes were found before and after embolism. We conclude that minipigs, compared with dogs, present with a higher pulmonary vascular resistance and reactivity and adapt to embolic pulmonary hypertension by an increased Zc without earlier wave reflection. These differences allow for a reduced pulsatile component of hydraulic power and, therefore, a better energy transfer from the right ventricle to the pulmonary circulation.

Left ventricular outflow tract obstruction after mitral valve replacement.

We describe a patient with left ventricular outflow tract obstruction after mitral valve replacement preserving the anterior subvalvular apparatus. Postoperative transesophageal echocardiography demonstrated systolic narrowing of the left ventricular outflow tract by a bulging septum and systolic anterior motion of the preserved anterior mitral leaflet. Septal myectomy and transaortic mitral apparatus resection enabled us to relieve the left ventricular outflow tract obstruction. This suggests that septal hypertrophy might be a relative contraindication to the preservation of the anterior mitral subvalvular apparatus in mitral replacement.

Systemic vascular effects of isoflurane versus propofol anesthesia in dogs.

Vascular effects of general anesthesia are usually described by changes in vascular resistance, which assumes a linear pressure-flow relationship passing through the zero-flow zero-pressure point, and neglects the pulsatile properties of the circulation. We compared the systemic vascular effects of isoflurane versus propofol anesthesia by measurements of aortic pressure-flow relationships, systemic vascular impedance (SVZ), and pressure transfer function (PTF). Eight mechanically ventilated dogs received isoflurane 1.4% end-tidal and propofol 18 mg.kg-1.h-1 in a random sequence. During both periods, pressure-flow data and SVZ data were obtained at baseline and after stepwise reduction of the cardiac output by inflation of a balloon in the inferior vena cava. Instantaneous pressure and flow were measured at the aortic root using a micromanometer-tipped catheter and an ultrasonic flow probe. Compared to baseline, low flow decreased the aortic pressure and increased the resistance, characteristic impedance, and oscillatory/total work ratio. Compared with isoflurane, propofol resulted in higher aortic pressure, lower characteristic impedance, and lower oscillatory/total work ratio. Low-frequency PTF moduli decreased at low flow and increased with propofol. We conclude that, compared with isoflurane, propofol better preserves aortic pressure and increases aortic compliance, and thus improves the energy transmission from the left ventricle to the arterial system.

Severe syncope due to the application of a pacemaker telemetry wand.

We report a case of a transient defective anodal contact between pacemaker ground plate and patient's tissues (the so-called dry pocket). During unipolar-DDD pacing, mild compression of the pocket with the telemetry head caused a severe syncope, due to asystole and secondary to complete loss of ventricular capture. Normal pacemaker function resumed with bipolar pacing configuration.

Pulmonary vascular impedance response to hypoxia in dogs and minipigs: effects of inhaled nitric oxide.

The pig has been reported to present with a stronger hypoxic pulmonary vasoconstriction (HPV) than many other species, including dogs. We investigated [pulmonary arterial pressure (Ppa)-pulmonary arterial occluded pressure (Ppao)] vs. pulmonary blood flow (Q) relationships and pulmonary vascular impedance (PVZ) spectra in nine minipigs and nine weight-matched dogs. The animals were anesthetized and ventilated in hyperoxia [inspired O2 fraction 0.4] or hypoxia (inspired O2 fraction 0.12). PVZ was computed from the Fourier series for Ppa and Q. In hyperoxia, the pigs had a higher Ppa (26 +/- 1 vs. 16 +/- 1 mmHg), a higher first-harmonic impedance (Z1), and a more negative low-frequency phase angle but no different characteristic impedance (Zc) compared with the dogs at the same Q. Hypoxia in the dogs increased (Ppa-Ppao) at all levels of Q studied by an average of 2 mmHg but did not affect Z1 or Zc. Hypoxia in the pigs increased (Ppa-Ppao) at all levels of Q by an average of 13 mmHg and increased Z1 and Zc. Inhaled NO (150 ppm) reversed the hypoxia-induced changes in (Ppa-Ppao)/Q plots and PVZ in the dogs and pigs. However, differences in (Ppa-Ppao)/Q plots and PVZ between the dogs and pigs in hyperoxia and hypoxia were not affected by inhaled NO. We conclude 1) that minipigs present with an elevated pulmonary vascular resistance and impedance in hypoxia more than in hyperoxia and 2) that baseline differences in pulmonary hemodynamics between dogs and minipigs are structural rather than functional.

Effects of a chronic aortopulmonary shunt on pulmonary hemodynamics in piglets.

Systemic-to-pulmonary shunting in growing pigs has been proposed as an experimental model of high-flow pulmonary hypertension associated with congenital heart defects. We investigated multipoint pulmonary arterial pressure (Ppa) vs. cardiac output (Q) plots and pulmonary vascular impedance spectra in 13 piglets aged approximately 4 mo and ventilated alternatively in hyperoxia (inspired O2 fraction 0.4) and in hypoxia (inspired O2 fraction 0.12). The measurements were done 8 wk after either an anastomosis between the thoracic aorta and the pulmonary trunk (n = 7 piglets) or a sham operation (n = 6). Cardiac output was altered by a manipulation of venous return. In the sham-operated piglets, hypoxia increased Ppa by an average of 12 mmHg over the entire range of Q studied, from 60 to 120 ml/kg, and increased both 0 Hz (Z0) and characteristic (Zc) pulmonary vascular impedance. In the shunted piglets compared with the sham-operated piglets in hyperoxia, Ppa was increased by an average of 5-6 mmHg at all levels of Q studied, from 60 to 120 ml/kg (P < 0.01), and Zc was also increased (P < 0.01), whereas Z0 was unchanged. In the shunted piglets, hypoxia increased Ppa at all levels of Q studied only to an average of 3 mmHg, and neither Z0 nor Zc was altered by hypoxia. We conclude that an aortopulmonary shunt of 2-mo duration in growing pigs increases both pulmonary vascular resistance and impedance and is associated with a blunting of pulmonary vascular reactivity to hypoxia.

Comparison of the hemodynamic responses to molsidomine and isosorbide dinitrate in congestive heart failure.

To evaluate the mechanisms involved in nitrate tolerance, we randomized 23 patients with congestive heart failure resulting from coronary artery disease to an isosorbide dinitrate or a molsidomine infusion. The drugs were titrated to decrease pulmonary capillary wedge pressure by > or = 30% or > or = 10 mm Hg. Then isosorbide dinitrate, molsidomine, or placebo was infused in a double-blind randomized manner for 24 hours. In all patients, treatment with enalapril was begun > or = 48 hours before the beginning of the protocol and was continued throughout the study to avoid renin-angiotensin activation. The pulmonary capillary wedge pressure remained significantly decreased at 24 hours during molsidomine infusion only. No significant increase in catecholamines occurred. Because molsidomine differs from organic nitrates by its property of directly stimulating guanylate cyclase without depending on thiol group availability, these results suggest that impaired biotransformation of nitrates is involved in tolerance induced by high doses of isosorbide dinitrate in congestive heart failure.

Increased left atrial pressure inhibits hypoxic pulmonary vasoconstriction.

An increase in left atrial pressure (Pla) has been reported to either inhibit or not affect hypoxic pulmonary vasoconstriction in intact dogs. We investigated mean pulmonary arterial pressure (Ppa)-flow (Q) relationships at low and high fixed Pla and Ppa-Pla relationships at fixed Q in piglets, which are known to present with a stronger hypoxic pulmonary pressor response than dogs. Seven piglets were anesthetized; equipped with balloon catheters in inferior vena cava and left atrium to control Q and Pla, respectively; and ventilated alternatively in hyperoxia [fractional concn of O2 in inspired air (FIO2) 0.4] and hypoxia (FIO2 0.12). In all experimental conditions, Ppa-Q plots were best described by a linear approximation with extrapolated pressure intercepts (Pi) not different from Pla. Hypoxia increased slope but not Pi of Ppa-Q plots. An increase in Pla from 8 to 17 mmHg induced a parallel shift of Ppa-Q plots to higher Ppa in hyperoxia but did not affect Ppa-Q plots in hypoxia. In hyperoxia, an increase in Pla at constant Q induced an approximately equal increase in Ppa, whereas in hypoxia there was no effect. The hypoxia-induced increase in Ppa was blunted by increased Pla at all levels of Q studied. We conclude that in anesthetized piglets at fixed Pla hypoxia increases the slope of Ppa-Q plots without affecting Pi and an increase in Pla inhibits hypoxic pulmonary vasoconstriction. The results suggest that no closing pressure higher than normal Pla contributes to hyperoxic or hypoxic Ppa in the intact porcine pulmonary circulation.

Stimulus-response curves for hypoxic pulmonary vasoconstriction in piglets.

OBJECTIVE: The aim was to characterise stimulus-response curves for hypoxic pulmonary vasoconstriction and to observe the effects of drugs reputed to enhance it: aspirin (a cyclo-oxygenase inhibitor), and doxapram (a peripheral chemoreceptor agonist). METHODS: Mean pulmonary artery pressure (Ppa) versus fraction of inspired O2 (FIO2) relationships were studied in 18 intact anaesthetised piglets, before and after the intravenous administration, in random order, of either physiological saline, 1 g aspirin, or 20 mg.kg-1 doxapram. Cardiac output (Q) was kept constant, to avoid passive Q dependent changes in Ppa. RESULTS: A progressive decrease in FIO2 from 100% to 12% was associated with an average increase in Ppa from 19 to 38 mm Hg (p < 0.001). When FIO2 was further decreased to 8%, Ppa decreased to 32 mm Hg (p < 0.01). This stimulus-response curve was unaffected by saline, but displaced in a non-PO2-dependent manner to higher Ppa by doxapram and by aspirin. CONCLUSIONS: The pulmonary vascular response to inspiratory hypoxia in intact anaesthetised piglets is biphasic, with a maximum at an FIO2 of 12%. Neither aspirin nor doxapram affect the shape of this stimulus-response curve, and in particular do not prevent low FIO2 associated inhibition of hypoxic pulmonary vasoconstriction.

Adenylate cyclase activity in crude liver membranes during chemical hepatocarcinogenesis in portacaval shunted rats.

Hepatocarcinogenesis was initiated in rats with diethylnitrosamine (DEN) followed by a selection with 2-acetylamino-fluorene (2-AAF). Portacaval shunt was then performed in order to promote tumor development. Control rats were not submitted to the initiation--selection protocol and were sham-operated. In control rats, adenylate cyclase activity from crude liver membranes was stimulated 7- to 8-fold by maximal doses of glucagon (10(-6) M) or guanyl-5'-yl-imidophosphate [Gpp(NH)p] (10(-3) M), and 17-fold by a maximal (10(-5) M) dose of forskolin. Guanosine-5'-O-(2-thiodiphosphate) inhibited the response to forskolin (-38%) and to low doses of glucagon (-50%). The initiation--selection protocol increased the activity in basal conditions and in response to various stimuli. The portacaval shunt did not modify the activity of the enzyme with respect to basal activity or the response to glucagon. It significantly decreased the response to Gpp(NH)p (-45%) and to forskolin (-27%). The initiation--selection protocol increased the basal activity of the enzyme (+150%) and its response to Gpp(NH)p (+300%). When tumors developed, the activity of the cyclase further increased (+200%) and an inhibitory effect of GTP on the hormone-stimulated enzyme appeared (-40%). From these results, it is concluded that the promotion of hepatocarcinogenesis by portacaval shunt is coupled with modifications in the activity of adenylate cyclase in response to glucagon and guanylnucleotides.

Adenylate cyclase activity in crude liver membranes during chemical hepatocarcinogenesis.

Crude plasma membranes were prepared from the liver of control rats or of rats submitted to an initiation by diethyl-nitrosamine and selection with 2-acetylaminofluorene and carbon tetrachloride (group IS) or of rats submitted to an initiation-selection protocol followed by a promotion with phenobarbital (group IS PB). In control rats, the diterpene forskolin and glucagon stimulated the activity of adenylate cyclase 6- to 7-fold. Guanosine-5'-O-(2-thiodiphosphate) (GDP beta S) inhibited the stimulation by both agents and the non-hydrolyzable GTP analog, guanyl-5'-yl-imidodiphosphate [Gpp(NH)p], potentiated the stimulatory effect of glucagon. In rats of the IS group, no modification of the activity of the liver cyclase was found, except for an increased response to forskolin and glucagon. In the IS PB group, for the rats without tumor, the only effect of adding phenobarbital was to increase the sensitivity of the cyclase to forskolin. In tumoral tissue, the response to Gpp(NH)p, glucagon and forskolin were increased when compared to the surrounding tissue. In contrast to the surrounding tissue, GDP beta S potentiated the stimulatory effect of forskolin. When the affinity of the glucagon receptors for the hormone was measured in binding experiments, no difference was observed among the rats of the various groups, except for a higher affinity in tumoral tissue. Similarly, GTP inhibited the binding of glucagon with the same potency in each group. It is concluded that during hepatocarcinogenesis, the sensitivity of the adenylate cyclase towards glucagon increases secondarily to a better binding of the hormone to its receptor and to an impairment of the inhibitory regulatory site.

[Contribution of epidural anesthesia and general anesthesia to colon surgery]. / Contribution de l'anesthésie épidurale à l'anesthésie générale en chirurgie colique.

The authors, having clinically observed favourable post operative effects on patients operated under combined general and epidural anaesthesia in digestive surgery, have proceeded to a retrospective and comparative study of the last 50 colic resections. They have observed: a +/- 50% reduction of the quantity of morphine used; a +/- 50% reduction of the time required for peristaltic resumption; a +/- 50% reduction of the time required for gastric intubation thereby contributing to carefree post-operation effects in colic surgery where a series of known complications are usually to be expected. They are of opinion that the benefit of epidural anaesthesia is due essentially to the preponderance of the para sympathetic nervous system allowing the release of some hormones with intestinal tropism as well as the disappearance of the negative action of the splanchnic vaso-constriction.