Results of myocardial revascularization by two internal thoracic arteries using a Y-shaped conduit.

MATERIAL AND METHODS: Between August 2002 and September 2004, 276 patients with coronary artery disease underwent surgical treatment using a Y-shaped conduit formed from two internal thoracic arteries (ITA). In 268 (97.1%) patients, myocardial revascularization required exclusively bi-mammary bypass grafting. In creation of the Y-shaped conduit in the capacity of a free transplant, the intercepted right ITA was connected to the left internal thoracic artery (LITA). In the remaining 7 (2.5%) patients, venous bypasses together with the internal thoracic arteries were employed: in one patient (0.36%), the radial artery was used. RESULTS: Three patients (1.08%) died after operation. The survival rate accounted for 98.4%. CONCLUSION: The use of two internal thoracic arteries for complete myocardial revascularization provided beneficial results in the short- and long-term postoperative periods.

Clinical evaluation of the Physio annuloplasty ring.

STUDY OBJECTIVES: Prospective evaluation of a selectively flexible annuloplasty ring was undertaken to assess its safety and efficacy. PATIENTS: Between December 1992 and November 1996, 190 patients with mitral regurgitation underwent mitral valve repair using an annuloplasty ring (Carpentier-Edwards Physio; Baxter-Edwards CVS Laboratories; Irvine, Calif). Ninety-four were in New York Heart Association class I or II. Etiology was degenerative in 74% of the patients. RESULTS: Four patients died early for a hospital mortality of 2.1%, and one late death occurred. Two patients with systolic anterior motion required early valve replacement. Two transient episodes of hemiparesis occurred during the first postoperative month. There were no late thromboembolic complications, no late reoperation, and no endocarditis. Mean follow up of 23+/-13 months was complete in 99% of the patients. Seventy-seven patients (40.5%) have had Doppler echocardiography > 1 year after surgery: 61 (80%) of them have no residual regurgitation, 15 have grade 1+/4+ mitral regurgitation, while 1 has grade 2+/4+ insufficiency. Left ventricular end-diastolic volume index (mL/lm2) decreased from 107.4+/-35.5 preoperatively to 74.2+/-24.4 at last control (p<0.001). CONCLUSION: The physio annuloplasty ring provided reliable and stable results at medium-term follow-up with a very low incidence of valve-related complications.

Transposition of posterior leaflet for treatment of ruptured main chordae of the anterior mitral leaflet.

A 13-year-old girl with mitral regurgitation resulting from rupture of multiple chordae of the anterior leaflet had repair by transposition of a part of the posterior leaflet to the free edge of the anterior mitral cusp. Postoperative clinical hemodynamic, and angiographic studies showed perfect function of the mitral valve. This technique seems to be a good solution for mitral repair in the presence of ruptured anterior mitral chordae.

Mitral reconstructive operations. A series of 130 consecutive cases.

Between January, 1975, and January, 1982, 130 patients underwent mitral valvuloplasty for pure or predominant mitral insufficiency. Mean age at operation was 30 +/- 17 years. Twenty-five patients were under 15 years of age. Mitral insufficiency was mainly (112/130) due to rheumatic disease. Fifty-nine patients (45.4%) had another diseased valve which necessitated a surgical correction (tricuspid in 36 and aortic in 23). Surgical technique for mitral valvuloplasty varied according to the lesions. Three patients died in the first month after operation (2.3%). Five patients are lost to follow-up. The mean follow-up period for the 122 remaining patients is 38 +/- 27 months. Seven patients required reoperation and three of them died. An additional patient died without reoperation. Therefore, the late mortality was 3.1% (4/122). Almost all (116/118) of the remaining patients are in Class I (105) or II (11) of the New York Heart Association. Mean cardiothoracic ratio decreased from 60.6% +/- 7.7% preoperatively to 53.7% +/- 6.2% postoperatively (p less than 0.001). Thromboembolic episodes were noted in four patients, all of them in atrial fibrillation. Actuarial curves including hospital mortality showed a 92.0% survival rate at 7 years for the overall series (1.0% +/- 0.5%/patient-year), 93.7% +/- 4.9% at 7 years for isolated mitral reconstruction and 89.9% +/- 5.6% for mitral-tricuspid valvuloplasty at 5 years. The embolism-free rate at 7 years was 91.2%, with a rate of thromboembolic episodes of 1.0 +/- 0.5%/patient-year. Eighty-eight percent were free of reoperation at 7 years, with a rate of reoperation of 1.7 +/- 0.7%/patient-year. This system of mitral repair can provide stable functional results, low surgical and late mortality, and an acceptable rate of reoperation.

Reconstructive surgery of mitral valve incompetence: ten-year appraisal.

Between January, 1969, and January, 1978, 551 patients with mitral incompetence were treated by a system of reconstructive techniques. Mitral valve incompetence was classified into three types according to leaflet pliability; type I normal leaflet motion, 150 cases; type II, leaflet prolapse, 213 cases; and type III, restricted leaflet motion, 188 cases. Associated tricuspid valvular disease was present in 174 cases (31.5%) and was treated by prosthetic ring annuloplasty. The operative mortality rate was 4.2% (16/377) in the mitral group and 14% (25/174) in the mitral-tricuspid group. Follow-up data are available in 341 patients from 1 year to 10 years (average 4 1/2 years). The late mortality rate was 7% (24/341). Actuarial curves including hospital mortality rate show an 82% survival rate at 9 years in the mitral group and a 79% rate in the mitral-tricuspid group. Thirty-seven patients (11%) underwent reoperation mainly for residual (17) or recurrent (16) mitral incompetence. Thromboembolism occurred in 12 patients for an embolic rate of 0.6% per patient-year, even though 48% were not given anticoagulants. Acorrding to the New York Heart Association (N.Y.H.A.) classification, 76% (207/270) of the patients were in Class I, 19% (51/270) were in Class II, 4% (10/270) were in Class III, and 0.7% were in Class IV (2/270). Results of postoperative catheterization and angiocardiography are available in 52 patients. Comparison between the various groups shows that the best results were obtained in type II mitral incompetence, followed by type I and type III mitral incompetence. This experience demonstrates that predictable and stable long-term results have been achieved by techniques of valvular reconstruction with a low incidence of thromboembolism. Reproducibility of the techniques is a limiting factor which can be overcome by adequate training and progressive experience. Patient selection is based on the valvular disease rather than age, physical condition, or cause of valvular disease.

Mitral valve repair: results and the decision-making process in reconstruction. Report of 275 cases.

From January 1975 to June 1988, 275 patients underwent mitral valve repair for mitral regurgitation, pure (148 patients) or associated with mitral stenosis (127 patients). Patients with pure mitral stenosis were excluded from this study. The cause of mitral regurgitation was rheumatic in 180 patients (aged 28.6 +/- 1.2 years, mean +/- standard error of the mean) and degenerative in 84 patients (aged 54.7 +/- 1.5 years). Fifty-nine percent of the patients were in New York Heart Association classes III and IV before the operation. Intraoperative assessment of the mitral valve led us to identify four major mechanisms of mitral regurgitation: (1) restriction of leaflet motion by fibrosis (group I, 63 patients); (2) enhancement of leaflet motion by leaflet and chordal extension and prolapse (group II, 139 patients), (3) combination of both (group III, 64 patients); and (4) isolated dilatation of the anulus (group IV, 10 patients). One hundred sixty-one patients had isolated mitral disease and 114 had associated aortic or tricuspid valve disease, or both. The hospital mortality rate was 4.0%. Follow-up was 96% complete and totaled 1247.47 patient-years. At 13 years' follow-up, the survival rate was 93.0% +/- 6.8% in group I, 90.0% +/- 6.0% in group II, and 96.6% +/- 4.6% in group III. Freedom from reoperation was 78.1% +/- 21.0%, 83.2% +/- 18.9%, and 79.6% +/- 16.2%, respectively. Freedom from embolism was 94.7% for the whole series. In patients with isolated mitral valve repair, the cumulative morbidity was significantly higher in groups I (6.3 +/- 2.0%/pt-yr) and III 6.3% +/- 1.7%/pt-yr) than in group II (2.5% +/- 0.9%/pt-yr, p less than 0.05). Multivariate analysis identified age and associated tricuspid valve disease as significant predictors of reoperation (p less than 0.01 for both factors). These results suggest that conservative surgery should be used with caution in group I and III patients. In contrast, indications for mitral valve repair should be extended in group II patients. This observation has important clinical implications since, in Western countries, valve prolapse tends to be a major cause of mitral regurgitation.

Surgical treatment of asymptomatic and mildly symptomatic mitral regurgitation.

OBJECTIVE: The purpose of this study was to review the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation and no or mild symptoms. METHODS: From January 1989 to December 1994, 584 patients were operated on for mitral regurgitation. Of these, 175 patients were in New York Heart Association class I or II with grade 3 to 4 isolated chronic mitral regurgitation. They comprise our study population. Mean age was 51.3 +/- 14.3 years. Principal causes of mitral regurgitation were degenerative in 128 (73%) and rheumatic in 26 patients (15%). Leaflet prolapse was the mechanism responsible for regurgitation in 152 patients (86%). Mitral valve repair was performed in 174 patients, and one patient required initial valve replacement. Mean follow-up was 34.3 +/- 18.8 months. RESULTS: Three patients died, for an overall mortality of 1.7%. Five patients were reoperated on, for an actuarial freedom from reoperation of 97.0% +/- 0.8% at 5 years. Actuarial freedom from thromboembolism and endocarditis was 96.3% +/- 1.7% and 99.4% +/- 0.6%, respectively, for an event-free survival of 91.0% +/- 2.0% at 5 years. Left atrial diameter decreased from 54.3 +/- 11.6 mm to 43.6 +/- 10.5 mm (p < 0.001). Left ventricular end-systolic and end-diastolic diameters decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001), respectively. Mean residual mitral regurgitation was 0.44 +/- 0.6. CONCLUSION: Mitral valve repair for chronic mitral regurgitation in patients having mild or no symptoms was performed with low mortality and morbidity, good valve function, and preserved late left ventricular performance. Early repair may be advocated on the basis of severity of regurgitation and valve repairability, regardless of symptoms.

Effective reduction of a giant left atrium by partial autotransplantation.

Although many surgical procedures have been proposed to reduce the size of a left atrium, their effectiveness is not well established. We present a case of mitral and tricuspid valve insufficiency with a giant left atrium. Partial heart autotransplantation was used in a mitral and tricuspid valve operation with a successful outcome. This procedure can be an effective method to treat giant left atrium.

Advancement flaps to treat superficial wound infections after cardiac operations.

The management of superficial sternal wound infections is not well-codified. In case of large necrosis or tissue defect we use a two-stage approach, consisting of a first surgical debridement, followed a few days later by wound closure by means of two lateral advancement flaps. We have used this technique with good cosmetic results and shorter hospital stays.

Tricuspid valve incompetence caused by nonpenetrating thoracic trauma.

Tricuspid valve incompetence from ruptured papillary muscle or chordae as a result of nonpenetrating trauma is uncommon. Blunt trauma causing partial detachment of a leaflet from the annulus is very rare. We report the case of a young adult involved in a car accident who had these findings. Operative repair with resuture of the leaflet to the annulus and annuloplasty using a Carpentier ring resulted in complete recovery.

Treatment of ruptured or elongated anterior mitral valve chordae by partial transposition of the posterior leaflet: experience with 29 patients.

We report a series of 29 patients, 5 to 75 years of age (mean age, 31.8 +/- 21.4 [SD] years), with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. These patients underwent mitral valve repair by segmental transposition of the posterior leaflet with its attached chordae sutured to the free edge of the flail anterior leaflet. There were 2 hospital deaths. Follow-up ranged from 1 to 35 months (mean follow-up, 14.9 +/- 8.5 months). One patient is lost to follow-up. Two patients are in New York Heart Association Functional Class II; all others are in Class I. In 17 patients there is no detectable murmur; in 5 patients a mild to moderate systolic murmur can be detected, while 4 have a marked systolic murmur. The adequacy of the repair could be confirmed by Doppler echocardiography, which has shown no evidence of prolapse in 22 patients. A mild regurgitation jet is present in 4 patients, and a marked jet, in 3. Postoperative cardiac catheterization performed in 5 patients has confirmed the Doppler echocardiographic findings. Although longer follow-up is necessary, this technique appears adequate for repairing a major prolapse of the anterior leaflet caused by multiple ruptured or elongated chordae, therefore obviating the need for a prosthetic valve substitute.

The "physio-ring": an advanced concept in mitral valve annuloplasty.

BACKGROUND: A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. METHODS: From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. RESULTS: Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. CONCLUSIONS: This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Beyond cold cardioplegia.

One hundred fifteen consecutive patients were operated on for myocardial revascularization or valvular disease or both with continuous antegrade and retrograde aerobic warm (37 degrees C) blood cardioplegia. Mean cross-clamp time was 56.3 +/- 21 minutes (+/- standard deviation). Mean reperfusion time was 18.4 +/- 11.8 minutes (range, 5 to 81 minutes). Five patients (4.3%) died, and 15 (13%) needed inotropic support. Two (1.7%) required intraaortic balloon support. Two patients (1.7%) had evidence of perioperative myocardial infarction, and 98 (85%) returned spontaneously to normal sinus rhythm. Sixteen patients had a cross-clamp time greater than 80 minutes. All 16 of them had an uneventful postoperative course except for 1 patient who required inotropic drugs. This method of myocardial protection is now used for all open heart procedures in our institution.

Beyond hyperkalemia: beta-blocker-induced cardiac arrest for normothermic cardiac operations.

BACKGROUND: Four experimental protocols were carried out to assess the ability of esmolol to induce and maintain reversible cardiac arrest under continuous normothermic (37 degrees C) perfusion. METHODS AND RESULTS: In the first protocol, 8 perfused rat hearts were subjected to 20, 60, 90, and 120 minutes of esmolol arrest, after which positive and negative first derivative of pressure, heart rate, left ventricular developed pressure, and left ventricular end-diastolic pressure were evaluated. Arrest was achieved 45 to 60 seconds after beginning the infusion of esmolol. Mechanical arrest was achieved before electrical arrest. In the second protocol, dose-response curves were obtained using isolated (Langendorff) rat and rabbit (n = 6) hearts. The concentrations of esmolol varied from 0.084 to 6.7 mmol/L and from 0.12 to 1.45 mmol/L in the rat and rabbit heart experiments, respectively. In the third protocol, the effects of 20 minutes of normothermic (37 degrees C) ischemia on the function of isolated rat hearts perfused with esmolol-containing Krebs solution were compared with those using high-potassium (25 mmol/L) Krebs solution. Group A subjects (n = 9) received the ischemic injury after being perfused (and arrested) for 20 minutes with either esmolol or potassium (KCl, 25 mmol/L). Group B subjects (n = 10) received the same ischemic insult before being perfused with either esmolol or potassium. Esmolol-treated hearts showed better recovery than those receiving potassium, in terms of +/- dP/dt (p < 0.01), left ventricular systolic pressure (p < 0.01), and left ventricular developed pressure (p < 0.009). Finally, the fourth protocol was done to evaluate the effects of esmolol in a clinically relevant experimental model. Pigs were divided into esmolol (n = 6) and potassium (n = 5) groups and subjected to normothermic cardiopulmonary bypass and a 1-hour period of cardiac arrest. Twenty minutes after stopping infusion of the cardioplegic agents, all animals were weaned off bypass. There were no statistically significant differences between the groups. CONCLUSIONS: Esmolol hydrochloride can be used as effectively as potassium for inducing and maintaining predictable and reversible cardiac arrest during normothermic cardiac operations.

Pressure-adjusted antegrade brain perfusion for surgery of the aortic aneurysm.

Determining cerebral blood flow during circulatory arrest in patients undergoing surgery for aortic aneurysms has been traditionally based on body weight. We report the use of per-aortic antegrade cerebral perfusion regulated by perfusion pressure using a triple lumen cardioplegia catheter thus optimising cerebral flow.

Retrocaval in situ RIMA for distal marginal arteries grafting.

The length of the in situ right internal mammary artery (RIMA) often restricts its use as a graft to distal marginal arteries. We describe herein a retrocaval supra-azygous extra-pleural passage of the RIMA that allows a significant gain in length. We report our experience in 30 patients with distal marginal lesions or with large hearts.

Pericardial patch for rapid and effective hemostasis of cardioplegia injection site.

Cardioplegia injection site may be the source of serious haemorrhagic complications either intraoperatively or during the early postoperative period. Here we describe a simple technique that allows a rapid control of hemostasis at this site. An autologous pericardial patch is used to repair and strengthen the aortic wall.

[Contribution of new technologies to the management of acute complications of coronary angioplasty]. / Apport des nouvelles technologies à la prise en charge des complications aiguës de l'angioplastie coronaire.

This retrospective study of 4,000 coronary angioplasty procedures performed between 1/1/87 and 31/1/92 was undertaken to assess the benefits of new therapeutic options (perfusion balloon catheter, temporary and permanent stenting, laser balloon angioplasty, cardiopulmonary bypass) in the management of major complications of angioplasty and to evaluate the results of emergency coronary bypass surgery. Angioplasty was performed before (1,000 angioplasties: Group 1) and after (3,000 angioplasties: Group 2) the introduction of these new techniques at the Centre cardiologique du Nord. Despite the increasing complexity of the clinical and angiographic features of the patients, the global results show a significant decrease in the rates of emergency bypass surgery (2.1% in Group 1 versus 0.7% in Group 2; p < 0.0015) and of periprocedural acute myocardial infarctions (1.8% in Group 1 versus 0.7% in Group 2; p < 0.015). The use of these new techniques in cases of acute complications of coronary angioplasty decreases the signs of ischaemia before surgery (61.9% in Group 1 versus 68.1% in Group 2; p < 0.05). Coronary bypass surgery was performed under haemodynamically stable conditions in all patients requiring the procedure in Group 2, enabling the surgeon to perform more complete revascularisation with implantation of the mammary artery in 50% of cases (9.5% of cases in Group 1; p < 0.001). The interval to emergency bypass surgery depends mainly on the rapidity of the operative decision in cases of failure of these new techniques.

[Heart surgery in normothermia and aerobiosis: apropos of 530 patients]. / Chirurgie cardiaque en normothermie et aéorobiose: à propos de 530 patients.

Between February and October 1991, 530 consecutive patients underwent myocardial revascularization or valvular surgery with warm continuous antegrade and retrograde cardioplegia (37 degrees C). Three hundred and thirty three patients had isolated myocardial revascularization, 159 valvular surgery alone and 25 had combined valvular and coronary bypass. The global mortality was 5.1%, 3.7% for coronary bypass, 7.5% for valvular surgery and 8% for combined valvular and coronary surgery. A multivariate analysis identified the "reperfusion time" as the only predictive factor of hospital mortality (p < 0.001). Intraortic balloon counterpulsation was required postoperatively in 3.2% of cases, 5.2% of coronary bypass and 0.8% of the valvular patients. Inotropic drugs were used to come off cardiopulmonary bypass in 16.5% of coronary and 37.5% of valvular patients. There were 0.9% perioperative infarctions: 1.2% in the coronary bypass cases and 0.6% in the valvular cases. Spontaneous return to sinus rythm was observed in 87.9% of cases. The average "reperfusion time" was 20.48 +/- 0.7 mn. Analysis of the influence of aortic cross clamp time on cardiac morbidity in two groups of coronary patients (Group I: short cross clamp time less than 60 mn; Group II: long cross clamp time, 60 to 33 mn) showed that the hospital mortality, the prevalence of the use of inotropic drugs and balloon counterpulsation the postoperative cardiac index, the rate of spontaneous de fibrillation and the reperfusion time did not depend on the aortic cross clamp time. Cardiac morbidity.

[Treatment of anterior mitral valve prolapse by partial transposition of the posterior leaflet. Apropos of 7 cases]. / Traitement des prolapsus de la valve antérieure de la mitrale par transposition partielle de la valve postérieure. A propos de 7 cas.

Seven patients aged 8 to 62 years with massive mitral regurgitation due to anterior leaflet prolapse related to rupture or elongation of the chordae tendinae underwent reconstructive mitral valvuloplasty between June 1984 and September 1985, consisting in transposition of a bandlet of the posterior leaflet and its chordae to the free edge of the anterior leaflet. Medium term results with 2 to 16 months follow-up (average 8 months) showed all patients to have returned to Class I of the NYHA Classification; 5 patients had no systolic murmur, a mild systolic murmur 1 and 2/6 was present in 2 cases. The quality of the repair was confirmed by pulsed Doppler examination in all patients and by catheterisation and angiography in 3 cases. This surgical technique offers a good solution to the problem of mitral regurgitation due to severe prolapse of the anterior leaflet caused by rupture or elongation of the chordae tendinae.