Neointimal hyperplasia after stenting in a human mammary artery organ culture.

Although the use of stents has limited the incidence of restenosis, in-stent restenosis remains an important problem. In-stent restenosis is the result of a healing process that induced neointimal hyperplasia through mechanisms that are still not understood. The aim of this study was to analyze the histological consequences of the healing process following stent implantation. Internal mammary arteries from atheroslerotic patients undergoing coronary artery bypass surgery were stented and maintained in culture for 0-28 days. Stent implantation after predilatation induced an extensive loss of endothelial cells whereas direct stenting preserved endothelium between the struts. Morphometric analysis shows that stent placement induced neointimal thickening. Smooth muscle alpha-actin labeling indicates that neo-intimal formation was mainly due to proliferation and migration of smooth muscle cells. Smooth muscle cell proliferation, assessed by MIB-1 staining, was maximal at day 14 after stent insertion. Human mammary artery organ culture thus provides valuable information on histological consequences of stent implantation with or without predilatation regarding endothelial cell disappearance and neointimal hyperplasia. These data also demonstrate that neointimal thickening induced by stent implantation comprises an intrinsic component resulting from the vessel wall response to stent insertion and suggest that blood factors could play an amplifying but not necessary role.

[Surgery in heart failure (without transplantation)]. / Chirurgie dans l'insuffisance cardiaque (hors transplantation).

Cardiac transplant remains the treatment of reference for end-stage cardiac insufficiency. The very great disparity between the number of grafts available and the number of patients eligible to be included on the transplant list drives some of them to contemplate a surgical alternative in order to improve their clinical condition and to delay as much as possible the date of transplant. The objective is to treat surgically one or several of the lesions causing the cardiac insufficiency. It could be valvular surgery, coronary surgery or a combination of both, ventricular remodelling or cardiomyoplasty. It is coronary revascularisation surgery which gives the most spectacular results on condition that it is aimed at the myocardial zones for which viability has been demonstrated by stress echocardiography or a PET scan.

[Mid-term results of stentless bioprosthesis for aortic valve replacement. Experience in a series of 97 patients]. / Résultats à moyen terme des bioprothèses sans armature dans les remplacements valvulaires aortiques. Expérience nantaise sur une série de 97 patients.

Stentless bioprostheses have been described as valve substitutes of interest for aortic valvular replacement. We studied 97 consecutive patients with a mean age of 72.2 years (40-84) who underwent aortic valvular replacement with 80 Toronto SPV and 17 Freestyle prostheses. Operative mortality was 6.2. With a mean follow-up of 19 +/- 10 months (1-46), 87.2% of the surviving 86 patients underwent an echocardiography performed by the same operator. Mean gradient was 10.9 +/- 3.6 mmHg (4.2-22.6) and effective orifice area was 1.8 +/- 0.5 cm2 (0.8-3.0) for the 75 controlled stentless valves. The best haemodynamic data were obtained with the 25 mm diameter prostheses. One asymptomatic partial dehiscence was observed during monitoring. None of the 15 detected aortic leaks was significant. We observed a significant reduction of the ventricular mass in 41 patients who had undergone pre- and postoperative evaluation (p < 0.0014). Overall survival was 86.8 +/- 4.4% at 2 years. Stentless bioprostheses offered satisfactory haemodynamic results in our series. They however require an implantation technique learning curve as well as a thorough knowledge of the aortic root anatomy and physiology.

[Surgical treatment of pulmonary metastases of colorectal cancers. 8-year survival and main prognostic factors]. / Traitement chirurgical des métastases pulmonaires des cancers colorectaux. Survie à 8 ans et principaux facteurs pronostiques.

OBJECTIVE: In order to achieve a better definition of the indications for surgical excision of pulmonary metastases in colorectal cancer (CCR), a retrospective study of the eight year survival of patients who had been operated on was carried out with reference to the principal prognostic factors. METHODS AND RESULTS: Between May 1986 and December 1997, 38 patients had an excision for pulmonary metastases for CCR. The mean delay between diagnosis of the metastases and surgical treatment of the CCR was 39 +/- 24 months (0-98). Thirty two patients (84%) had a single pulmonary metastasis. The mean diameter of the metastasis was 38 +/- 22 mm. Twenty metastases had a diameter < 30 mm. Five patients had a locoregional recurrence of their CCR before pulmonary surgery. Fourteen patients had an abnormally elevated level of carcinoembrionic antigen (ACE-CEA) before the pulmonary excision. Five pneumonectomies, 23 lobectomies, 1 bilobectomy and 11 atypical resections were carried out. A lymph node clearance was performed in 25 cases. Six patients (16%) had an associated excision of an hepatic metastasis. The in-hospital mortality was 2.6%. Chemotherapy was associated with a pulmonary excision in 17 patients (46%). The mean survival was 2.7 years (0.13-8.7 years). The survival at one year was 89 +/- 5.2% and at five years 35.2 +/- 10.1% and at eight years 18.8% +/- 10.3%. Age, sex, histological stage of the primary tumor, the size and the delay in appearance in the pulmonary metastases, the number of metastases, the preoperative CEA, the operative technique and the perioperative chemotherapy did not influence the levels of survival at five years. At the same time associated excision of an hepatic metastasis did not worsen the prognosis at five years. CONCLUSION: Complete excision of pulmonary metastases in a colorectal cancer allows for significantly longer survival. This study associated with a literature review may help in advancing towards better selection of surgical candidates.

[Mucoviscidosis: lung transplantation is always in order]. / Mucoviscidose: la transplantation pulmonaire toujours d'actualité.

THE ONLY SOLUTION: Despite significant progress in the management of patients with multiple sclerosis, lung transplantation remains the only chance for survival in those with severe respiratory failure. WAITING LIST INCLUSION CRITERIA: Lung function tests, the patientís general states and psychological and familial factors all contribute to determining inscription on lung transplantation waiting lists. TECHNICAL ASPECTS: Heart-lung, monoblock two-lung and sequential two-lung transplantations are detailed according to the respective advantages and disadvantages. RESULTS: Hospital mortality is about 5% and 5-year survival about 50%. However, only 10% of the patients on waiting lists due to the lack of organs survive for 2 years. PERSPECTIVES: The number of grafts must be increased by developing lobular grafts from live donors using the bipartition technique. Nevertheless, xenografts remain the most promising perspective for increasing the number of patients who can benefit from this therapy.

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer.

OBJECTIVE: Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS: Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS: The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS: Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.

[A rare dyspnea in internal medicine: platypnea-orthodeoxia after pneumonectomy]. / Une dyspnée exceptionnelle en médecine interne: la platypnée-orthodéoxie après pneumonectomie.

BACKGROUND: A right-to-left shunting across a patent foramen ovale is a rare cause of acute respiratory failure after pneumonectomy. CASE REPORTS: We report two cases of posture dependent dyspnea (platypnea-orthodeoxia) secondary to postoperative right-to-left shunting across a patent foramen ovale. Both cases occurred three months after pneumonectomy, the first in a 63-year-old man and other in a 52-year-old man. CONCLUSION: A platypnea-orthodeoxia (dyspnea induced by the upright position with arterial deoxygenation relieved by recumbency) should lead to the diagnosis which is confirmed by echography or cardiac catheterization. The prognosis is good after surgical closure of the patent foramen ovale. The physiopathologic mechanism is poorly understood. We report two cases of platypnea-orthodeoxia.

Mitral valve replacement with the St. Jude Medical prosthesis: a 15-year follow-up.

BACKGROUND: A retrospective study was conducted to analyze the results of St. Jude Medical mitral valve replacement. METHODS: From January 1979 to December 1989, 870 patients (54% women, 46% men; mean age, 55.8 +/- 6.2 years) underwent mitral valve replacement with the St. Jude Medical prosthesis. Of these operations 616 were isolated mitral valve replacements and 254 were double valve replacements. Coronary artery bypass grafting was performed concomitantly in 55 patients (6.3%). RESULTS: Overall, early mortality was 5.05%, with 4.2% for the isolated mitral valve procedure and 7.08% for the double valve replacement. Follow-up at 15 years was complete in 859 patients (98.74%). Mean follow-up time was 93.5 months, for a total of 6,436 years. Actuarial survival at 15 years was 59.5% +/- 5%, 60.5% +/- 6%, and 56.9% +/- 9%, for the entire group, the isolated mitral valve and double valve procedures, respectively. Multivariate analysis identified age, sex, hospital stay, and preoperative mitral regurgitation as independent prognosis factors for overall mortality. Of 606 patients alive at the latest follow-up, the New York Heart Association class improved significantly (from 67% class III/IV before the operation to 88% class I/II after the operation). All patients received warfarin to maintain an international normalized ratio between 3.5 and 4. The linearized rates (% per patient-year) of thrombosis, thromboembolism, and major hemorrhage were, respectively, 0.21, 0.75, and 0.94 for the entire group; 0.18, 0.67, and 0.88 for the isolated mitral valve operation; and 0.15, 0.92, and 1.08 for the double valve replacement. For the entire group the freedom from thrombosis and thromboembolism at 15 years was 98.1% +/- 1% and 88% +/- 4%, respectively. No case of structural dysfunction occurred. The freedom from paravalvular leak and endocarditis at 15 years was 95.3% +/- 2% and 97.3% +/- 2.4%, respectively. The probability of remaining free from reoperation at 15 years was therefore 95.6% +/- 2.5%. CONCLUSIONS: These results confirm that the St. Jude Medical valve is a reliable prosthesis with very low thrombosis and thromboembolism rates, allowing the use of a low dose of anticoagulation with an international normalized ratio of about 3.

[Mycotic aneurysm in acute bacterial mitral valve endocarditis. Apropos of a case]. / Anévrisme mycotique au cours d'une endocardite mitrale bactérienne aiguë. A propos d'un cas.

A 24 year old man presented with acute endocarditis of the mitral valve. Rupture of a mycotic cerebral aneurysm on the 20th day was successfully treated by interventional catheterisation. Several days later, he underwent mitral valvuloplasty under good conditions. The postoperative period was uncomplicated but emergency surgery was required for a mycotic aneurysm of the superior mesenteric artery. The patient was discharged from hospital without severe neurological sequellae and with a continent mitral valve.

[Constrictive pericarditis after cardiac surgery]. / Péricardite constrictive après chirurgie cardiaque.

Constrictive pericarditis is a rare complication of cardiac surgery. Among 7851 patients who underwent cardiac surgery at Nantes University Hospital, postoperative constrictive pericarditis was diagnosed in 5 patients: 0.63%. All patients were men aged 49 to 77 years (mean 62.5) Four patients underwent coronary artery bypass graft surgery and one patient required mitral and aortic valve replacement. The mean time to onset of symptoms after the first operation was 21 months. The main clinical symptom was right ventricular failure. In all patients, the diagnosis was established by right catheterization which showed diastolic dip-plateau. A radical pericardectomy was performed in all but one of the patients, who was treated medically. Clinical signs resolved in all five patients. The diagnosis of constriction after cardiac-surgery is not easy, as the symptoms are non-specific. A symptomatic patient believed to have myocardial failure after cardiac-surgery could therefore actually instead have occult constriction.

[Pulmonary and cardiopulmonary transplantation in mucoviscidosis]. / Transplantation pulmonaire et cardiopulmonaire au cours de la mucoviscidose.

As early as 1987, several teams in France began lung transplantation for patients with cystic fibrosis. Most of these teams propose transplantation when the life expectancy is under 2 years. The major functional criteria are VEMS < 30%, PaC02 > 50 mmHg and PaO2 < 55 mmHg. This contribution focuses on psychologic, nutritional and infectious aspects required in preparing the patients for transplantation and on graft selection. Surgical techniques and patient care after transplantation are also reported. The overall probability of survival after transplantation for cystic fibrosis is 48, 35 and 29% at 1, 2 and 3 years respectively with wide intercentre variation. The lack of sufficient graft supply and the risk of post-transplantation degradation remain the two principal problems for transplantation in cystic fibrosis.

[Hydatid cyst of the interventricular septum. Apropos of a case]. / Kyste hydatique du septum interventriculaire. A propos d'un cas.

A cardiac tumour of the interventricular septum was detected in a young woman presenting with an ejectional systolic murmur. Surgical ablation was carried out before a precise diagnosis was made. Histopathological analysis of the surgical specimen confirmed a hydatid cyst. The main complication was complete atrioventricular block. This case underlines the difficulty of making the diagnosis of intracardiac hydatid disease in a non-specific context, because of the long period of clinical latency, despite the considerable aid of echocardiography and other medical imaging techniques (CT scan and magnetic resonance imaging.