[Acute suppurative mediastinitis in heart surgery performed under extracorporeal circulation]. / La médiastinite aiguë suppurée en chirurgie cardiaque sous circulation extracorporelle.

The incidence of acute suppurative mediastinitis after open heart cardiac surgery in a 5 year retrospective study was found to be 1.56%. The commonest causal agent was the DNAse + coagulase + staphylococcus (68.8%). All cases were treated with bactericidal antibiotics and local measures (dosed chest irrigation-drainage in 1 or 2 stages). Adult men, early and/or late reoperation, immediate postoperative complications (cardiovascular collapse, haemorrhage) were positive risk factors. On the other hand, the type of underlying cardiac disease, the duration of surgery and bypass time, emergency surgery, and protocols of prophylactic antibiotic therapy did not seem to influence this risk. No sources of exogenous contamination, no notions of epidemics or periodicity were discovered in this study. The clinical course may be complicated, especially by renal failure. Thirty-two of the 109 patients studied died. However, the prognosis has improved in the last 5 years in relation to technical advances in intensive care and, above all, to adoption of 1 stage dosed chest irrigation-drainage: the mortality rate has fallen from 37.2% in the first period to 20% more recently. When a cure is obtained, it is complete and there are no sequellae. Nevertheless, irrespective of the adoption of draconian measures of asepsis and protocols of prophylactic antibiotic therapy, the risk of acute postoperative mediastinitis persists. This suggests that the efficacy of the patient's local (and general) anti-infective immunity defenses may vary in the presence of constant mediastinal bacterial contamination despite aleatory preventive measures, due to the remenance of the skin flora.

[Acute thrombosis of the superior vena cava after cardiac surgery]. / Thrombose aiguë de la veine cave supérieure après chirurgie cardiaque.

One case of acute superior vena cava syndrome occurring twelve days after open-heart surgery was reported. The severity of the accompanying clinical signs led to the carrying out of an urgent superior vena cavogram. It revealed a superior vena caval obstruction by a thrombus which extended into the azygos vein; extrinsic compression was therefore ruled out. The thrombosis seemed to be due to direct trauma by the catheter or to the infusion of irritating solutions. Emergency thrombectomy was successfully carried out.

[Correction by a calcium inhibitor of a coronary spasm occurring during aortocoronary bypass]. / Correction par un inhibiteur calcique d'un spasme coronaire survenu en cours de pontage aorto-coronarien.

A case of recurrent coronary artery spasm after coronary revascularization under cardiopulmonary bypass is related. The spasm, which occurred under nitroglycerin perfusion, was suspected on the ECG tracing and confirmed during immediate reoperation. It was successfully treated with bepridil, a calcium-channel blocking agent. The use of such agents after cardiac surgery is discussed.

[Pheochromocytomas: diagnosis, anesthesia and treatment. Apropos of 17 recent cases]. / Phéochromocytomes: diagnostic, anesthésie et traitement. A propos de dix-sept observations récentes.

This article summarizes 5 years of systematic observation of 17 patients presenting with benign pheochromocytoma. The diagnosis was based on clinical and biological findings which were consistently positive. The topographical diagnosis was based on CT scans, and a combination of intravenous urograms and nephrotomography. The preoperative preparations were made with labetalol, and the anesthetic used was narconeuroleptanalgesic. The hemodynamic study was carried out with a Swann-Ganz catheter, which proved indispensable in the surveillance of the patient at operation. The surgical procedure is best performed with transperitoneal subcostal incisions, which the authors prefer. Morbidity was negligible, and mortality, zero.

Hemodynamic and metabolic effects of prostacyclin after coronary bypass surgery.

The hemodynamic and metabolic effects of prostacyclin (PGI2) were assessed in 12 patients who underwent coronary bypass surgery. PGI2 were injected intravenously at a rate of 2.5 ng/kg/min for 10 minutes, followed by three consecutive 10-minute injections of 5, 10 and 20 ng/kg/min. PGI2 infusion decreased systolic and diastolic arterial pressures by 17% (p less than 0.001) and increased cardiac index by 17% (p less than 0.001) without changing the heart rate. Right atrial, pulmonary arterial and pulmonary wedge pressures remained essentially unchanged. Total vascular resistance decreased by 37% (p less than 0.001). Rate-pressure product, an index of myocardial oxygen consumption, decreased by 13% (p less than 0.01), while stroke work index did not change. A 36% decrease in arterial PO2 (p less than 0.001) was the most consistent metabolic effect induced by PGI2 infusion. However, oxygen transport increased by 11% (p less than 0.05), suggesting that no decrease in peripheral oxygen supply was produced. Thus, PGI2 improved cardiac function and performance by a predominant effect on total vascular resistance. It may be valuable in the management of patients who undergo coronary artery surgery.

[Emergency in neo-natal surgery. High risks in forty-one cases (author's transl)]. / L'urgence en chirurgie cardiaque du petit enfant. Etude des facteurs de gravité à propos de 41 cas.

41 babies were operated upon in emergency in the cardiac surgery department. 11 of them were submitted to open heart surgery and 30 were operated without extra corporeal circulation. Amongst them, there were 21 coarctations of thoracic aorta either isolated or associated with other cardiac malformations. 13 of them, presented a pericardial effusion, and the mean age was 3 months. First of all, the notion of emergency in cardiac surgery of the new-born is stressed. Then, premedication and technic of anaesthesia are shortly described. The authors insist on the frequency of lethal cardiac fibrillation occurring at the opening of pericardium in case of coarctations of aorta complicated by pericardial effusion. Prevention of this accident is possible if at the beginning of anaesthesia the baby lies in a proclive position. On the opposite, bradycardia occurring at the opening of the pericardium or during pulmonary artery banding have a good prognosis. Lastly, the authors insist on the high risk of this surgery in the baby (25 p. cent of mortality) and 80 p. cent under 6 months of age and the high mortality of iterative operations.

[Clinical use of nitroglycerin as an hypotensive agent during general anesthesia for caesarean section. Report of a case (author's transl)]. / Utilisation de la nitroglycérine intraveineuse en solution aqueuse comme agent hypotenseur au cours d'une césarienne. A propos d'un cas.

Nitroglycerin in aqueous solution has been used as hypotensive agent during a caesarean section, in a patient who presented an arterial hypertension not controled by administration of four antihypertensive agents (acebutolol, clonidine, dihydralazine, alpha-methyl-dopa). Nitroglycerin continuous infusion started two hours before caesarean section at the dose of one milligramme over one hour and stopped several hours after.

[Nitroglycerin and anaesthesia in phaeochromocytoma (author's transl)]. / Utilisation de la nitroglycérine au cours de la chirurgie du phéochromocytome.

Six patients who have undergone surgery for phaeochromacytoma have been separated in 2 groups. In group I (n = 3) a nitroglycerin infusion of 7.8 microgram . kg-1 . mn-1 has been used before the removal of the tumor and no vasodilator drug was infused in group II. During the dissection, mean arterial pressure was significantly lower in group I (129 +/- 12 mm Hg) than in group II (172 +/- 17 mm Hg) (p < 0.05). After removal of the tumor the decrease in mean arterial pressure was lower in group I than in group II. In group I the maximal rise in mean arterial pressure (73 +/- 18 mm Hg) was significantly reduced compared to group II (134 +/- 20 mm Hg). These results show that nitroglycerin is an interesting substance to decrease the variations of arterial blood pressure and this effect is important to prevent cardiac complications during and after surgery.

[Pharmacology of nitroglycerin (author's transl)]. / Pharmacologie de la nitroglycérine.

Nitroglycerin is a vasodilating agent by virtue of its actions on vascular smooth muscle fibers. It may be administered intravenously (using either 5 p. cent dextrose, or propylene-glycol solvant), sublingually, orally or by topical administration. It is rapidly metabolized, principally by liver. Its is not toxic. The vasodilatation that is produced is both arterial and venous and is dose-related in dog (1 microgram to 100 micrograms/kg/min). However, resistance and tachphylaxis may occur. Its principal use is for angor treatment, but it has been used for the treatment of arteriopathy of the lower limbs, biliar hypertony and arterial hypertension. It has been recently administered for the treatment of acute phase of myocardial infarction and during pre, per- and post-operative periods in cardiac surgery, neurosurgery and hip surgery, as myocardial protector or anti-hypertensive agent or hypotensive agent. The absence of toxicity and the rapid reversibility of its cardio-vascular effects which are similar to the effects of sodium nitroprusside are important reasons for its use in anesthesia and cardiac intensive care.

[Nitroglycerin and amyl nitrite action on common bile duct during operation for vesicular lithiasis (author's transl)]. / Effects des dérivés nitrés sur le tonus des voies biliaires au cours de la chirurgie de la lithiase vésiculaire.

Eight patients undergoing cholecystectomy received a single injection of nitroglycerin (0,9 mg) and 8 received amyl nitrite, during a cholangio-kinesimetry. The maximum fall in common bile duct pressure was similar in both group; 3.2 +/- 0.3 torr after nitroglycerin (NTG),3.8 +/- 0.6 torr after amyl nitrite (AN). NTG caused a more persistent lowering of pressure than AN; 614 +/- 42 seconds/343 +/- 27 seconds (p < 0.001). This study showed that it is possible to produce a relaxation of biliary tract muscle fibres with an injection of nitroglycerin and then replace amyl nitrite during anesthesia.

[Anesthesia for aorto-coronary bypass]. / Anesthésie des pontages aorto-coronaires.

The authors have analysed a series of 357 patients undergoing aortocoronary bypass. The onset of complications was studied in relation to the past history, the anaesthetic protocol, the period of extra-corporeal circulation and the type of myocardial protection. Complications consisted of acute hypertensive episodes, arrhythmias, peroperative myocardial ischemia and myocardial infarction. The degree of beta-blocker therapy and above all its continuation up to the time of operation would seem to be an important factor in effective myocardial protection.

[Anesthesia and intensive care during aorto-coronary bypass surgery. Prospective study of 162 consecutive cases]. / Anesthésie-réanimation des pontages aorto-coronariens. Etude prospective de 162 cas consécutifs.

The authors studied a series of 162 patients undergoing surgery for aorto-coronary bypass by saphenous graft. In each case, the anesthetic technique was classical neuroleptanalgesia. Per and postoperative care included standard water and electrolyte balance, hpeparinisation from the 12th hour and routine prophylactic antibiotics. In addition, special treatment was given whenever necessary: vasodilators, essentially IV nitroglycerine; catecholamines; anti-arrhytmic agents; intra-aortic counter pulse balloon. The autors evaluate the effects of the use of these different types of treatment, in particular on electrocardiographic abnormalities and haemodynamic complications and analyse peri-operative mortality and morbidity.

[Prinzmetal's angina during myocardial revascularisation. Cardiovascular complications in 71 patients (author's transl)]. / L'angor de Prinzmetal au cours de la chirurgie du pontage aorto-coronaire. Comportement cardio-circulatoire de 71 malades.

71 patients undergo myocardial revascularisation for Prinzmetal's angina; among them, 50 p. cent are operated upon in emergency according to three ways of anaesthesia: neuroleptanalgesia, analgesic anaesthesia, combined anaesthesia. The authors lay stress on the importance of per- and post-operative complications: electrocardiographic ischemia in 22 p. cent of the cases, severe ventricular excitability perturbations were observed in 21 p. cent, myocardial necrosis in 14 p. cent, cardiovascular collapse in 21 p. cent and hypertensions in 22 p cent. These complications are often associated. In the discussion, the authors underline anesthetic induction as a cause of Prinzmetal's angina in 50 p. cent of the cases. They put the accent on the severity of peroperative crisis followed in 50 p. cent of the cases by serious ventricular excitability perturbations. In 25 p. cent of the cases myocardial necrosis is a complication of the spasm of a coronary artery. In this field, posterior necrosis are more frequent and correspond to the spasm of the right coronary artery. All the patients of this series, except one, develop necrosis in the spastic area (by-passed or not). Per-operative hypertension has no incidence on the occurrence of post-operative complications. Lastly, continuous per-operative infusions of nitroglycerine has been performed in several patients in order to reduce morbidity of this type of surgery.