Irreversible drop of systemic vascular resistances in patients implanted with a Jarvik total artificial heart.

Maintenance of the body's perfusion by a total artificial heart (TAH) may result in physiological alterations to the circulatory system. Little has been said about modifications to systemic vascular resistances (SVR) during TAH assistance. This paper reports on two patients implanted with a Jarvik - 70 cc TAH, who died after 1 and 3 days, both with an irreversible drop of SVR related to a complete loss of vascular tone but not related to sepsis. Activation of multiple cascades of inflammation, triggered by the extracorporeal circulation (ECC), is maintained during TAH support. Desperately sick patients might not be able to face the vaso-active situations created by the inflammatory response.

[Problems posed by preparation of the left ventricle for anatomical correction in simple transposition of the great vessels]. / Problèmes posés par la préparation du ventricule gauche à la correction anatomique de la transposition simple des gros vaisseaux.

Surgical correction of simple transposition of the great arteries by arterial detransposition can only be considered if the left ventricle is capable of functioning under systemic conditions. This is possible at birth but the operation is too big for it to succeed. After a few weeks the left ventricle may lose this capacity but it can be induced to redevelop if it is given a systolic stress by pulmonary banding. This was attempted initially in 30 children aged from 5 weeks to 3,5 years old (20 aged less than 2 months) but had to be abandoned for the following reasons: 8 immediate failures due to severe hypoxia and acidemia, 7 left ventricular failures, mainly in 3 children operated after 6 months of age; 7 severe hypoxemias, 5 pulmonary arterial lesions due to banding and/or the systemo-pulmonary anastomosis associated in some cases; in all, there were 8 failures out of the 17 anatomical corrections performed to date in 22 survivors of banding. The criteria of left ventricular readaptation after banding were difficult to determine. The final result did not appear to be related to either the duration of banding, the degree of aortic desaturation, the ratio of ventricular pressures, or to the various echocardiographic indices. Only the initial hypoxemia (less than 50 p. 100 saturation) with respect to the risk of banding, and the age at which banding was performed (over 6 months) with respect to the risk of anatomical correction, appeared to be obvious risk factors. This is the reason for a new protocol at present under study to try to maintain left ventricular growth by banding in the first days of life, so to ensure a more harmonious and effective, and also less dangerous preparation for anatomical correction. Six new born children have been "prepared" in this way: three had adequate loose banding and underwent atrial correction. Very good results were obtained in the other three patients who have already undergone detransposition at 2,5 and 3 months with excellent immediate results. We believe that neonatal pulmonary banding (before 5 days) when aortic saturation after atrioseptostomy is over 50 p. 100, provides a real alternative to the classical methods of treating simple transposition of the great arteries (Mustard or Senning). Anatomical correction can then be carried out a few weeks later under good conditions.

[New valvular homografts. Prospects and limits of their viability. Report of 42 implantations]. / Les nouvelles homogreffes valvulaires. Espoirs et contraintes de leur viabilité. A propos de 42 implantations d'homogreffes.

The regain of interest in aortic homograft bioprostheses is related to the prospects of improved viability resulting from explanation from organ donors, preservation in rich tissue culture media, together with the progress made in techniques of cryopreservation. Viability studies examining morphology of electron microscopy and tests of tissue culture confirm this notion of longer viability. These properties raise hopes of satisfactory long-term results while acknowledging outstanding antigenic problems which require strict A-B-O system compatibility. The results of a preliminary series of 42 valve homografts implanted at Henri Mondor Hospital over the last 5 years are reported. Twenty-one bioprostheses were implanted on the right side in congenital heart disease with good results in every case. Twenty-one were implanted in the aortic position in children and show no signs of degeneration as yet. One poor result was related to a technical error in calibration. The rebirth of this technique raises certain hopes, especially in aortic valve replacement.

[Aortic subvalvular obstructions. Anatomical forms and surgical treatment of 82 consecutive cases]. / Les obstacles sous-valvulaires aortiques. Formes anatomiques et traitement chirurgical de 82 cas consécutifs.

The authors report their experience of surgery for subvalvular aortic obstruction in 82 patients aged from 4 to 44 years (mean 15 years). Nearly one-half of the patients presented with symptoms; the others were operated upon for various reasons: gradient exceeding 60 mmHg, development or aggravation of aortic regurgitation, positive exercise test, electrocardiographic or echocardiographic signs of left ventricular repercussions. Nineteen children had previously undergone surgery for another malformation, but the subvalvular aortic obstruction had either been missed during this first operation or had developed subsequently. The diaphragmatic pattern was the most frequent (62 cases); the fibromuscular pattern was less common (9 cases) and the tunnel pattern (6 cases) was regularly associated in this series with hypoplasia of the aortic ring. Obstruction due to faulty insertion of the mitral valve was encountered on 3 occasions. The operative technique for each anatomical pattern is described. Tunnel obstructions did not require primary aortoventriculoplasty without prosthetic valve replacement of apicoaortic conduits. In addition to treatment of associated lesions (including 4 cases of ventricular septal defect), 9 aortic commissurotomies, 6 aortic valvuloplasties and 4 aortic valve replacements were performed. The transaortic gradient was dramatically improved. The aortic regurgitation murmur subsided with or, usually, without valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

[Operative risk in repeated heart valve replacement]. / Le risque opératoire des remplacements valvulaires itératifs.

Eighty three patients aged 7 to 74 years underwent 92 repeat valve replacement procedures on one or more valve prostheses (100 repeated valve replacements). Reoperation was performed for: dysfunction of a mechanical prosthesis (21%), degeneration of a bioprosthesis (13%) progressive prosthetic valve endocarditis (7%), aseptic or sterilised post-endocarditis perivalvular leak (39%), systemic complications (haemolysis or repeated embolism) (20%). Global hospital mortality (30 days) was 12%. Statistical analysis showed three factors were associated with increased operative risk: severe symptoms (Class III or IV) (mortality: 20% compared to 0%, p less than 0,001), emergency reoperation (mortality: 25% compared to 4%, p less than 0,01) and reoperation for a "high risk" indication (dysfunction of a mechanical prosthesis or progressive endocarditis) (mortality: 33% compared to 3%, p less than 0,001). These three factors reflect either the gravity of the complication or the severity of preoperative cardiac failure. On the other hand, when reoperation is carried out at an early stage, mortality is low, the same as that associated with primary valve replacement. The operative risk, therefore, appears to be related to the preoperative cardiac state and not to the technical surgical problems of reoperation. These results underline the necessity of preventing serious acute complications such as acute prosthetic valve thrombosis and endocarditis, and or reoperating chronic complications as soon as possible after diagnosis.

[Surgical treatment of valve prosthesis endocarditis]. / Le traitement chirurgical des endocardites sur prothèses valvulaires.

Between 1972 and 1982, 27 patients underwent 29 prosthetic valve replacements for infective endocarditis. Fourteen cases (48%) were operated in the acute infectious phase. Most patients (71%) had signs of cardiac failure and surgery was often performed as an emergency (78%). Twelve aortic valve prostheses (10 mechanical + 2 bioprostheses) and 2 mitral bioprostheses were infected. Four patients (29%) died in the postoperative period; all were in functional Class IV and were reoperated as an emergency. The infection only persisted in 1 patient (7%). Three patients died during follow-up (3 year survival: 46%). Three replacement prostheses developed perivalvular leaks (21%) and 2 were reoperated. Fifteen cases (52%) were operated after the acute infection for secondary lesions. These lesions affected an aortic valve prosthesis in 14 cases (9 mechanical and 5 bioprostheses) and 1 mechanical mitral valve prosthesis. Operative mortality was nil. Three patients died during follow-up (3 year survival: 67%). Five replacement prostheses developed perivalvular leaks (33%) and 3 had to be reoperated. These results show: that the high operative mortality (29%) in the group operated during the acute infectious phase is related to the preoperative haemodynamic condition and not to persistence of the infection (only 1 case); secondly, recurrent perivalvular leaks were common in both groups due to the fragility of the tissues and were the main cause of late mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aortocoronary bypass. Development of technics and indications over a 10-year period]. / Pontages aorto-coronaires. Evolution des techniques et des indications sur une période de 10 ans.

During the 1973-1983 period considerable changes have taken place in the techniques and indications of coronary bypass. In a homogeneous series of 3095 patients operated upon by the same group, changes in techniques have been: the introduction in routine coronary bypass of the membrane oxygenator which provides optimal biological conditions and the prolonged circulatory assistance so necessary to high risk patients, and the application to coronary bypass of microsurgical techniques enabling surgeons to perform multiple anastomoses on small vessels easily and safely. Changes in indications have been characterized by a progressive decrease in operations on patients with one-vessel lesions and normal left ventricular function to the benefit of those with multiple-vessel lesions and altered left ventricular function. As a result, the complete revascularization rate and the number of anastomoses have increased continuously. These two categories of changes have not modified the overall in-patient mortality rate, but there has been a significant increase in peri-operative necrosis.

Thrombocytosis after trauma: incidence, aetiology, and clinical significance.

BACKGROUND: Our aim was to assess the occurrence, aetiology, and clinical significance of a platelet count greater than 600 x 10(3)/mm(3) in trauma patients. METHODS: All trauma patients admitted to the intensive care unit (ICU) during a 13-month period were prospectively studied. Platelet counts were performed daily. We recorded the patient's age, sex, nature of trauma, severity of illness scores, episodes of infections in the ICU, acute lung injury, bleeding, and thromboembolic events. Patients with thrombocytosis were also followed during their hospital stay and 1 month after hospital discharge. RESULTS: A total of 176 patients were included. Thrombocytosis developed in 36 patients (20.4%) at a mean (sd) time of 14.0 (4.0) days and the platelet count normalized 35.0 (13.0) days after admission to the ICU. All patients with thrombocytosis had one or more possible predisposing conditions before the occurrence of thrombocytosis: nosocomial infection occurred in 30 patients (83%), acute lung injury in 17 (47%), bleeding in 27 (75%), and administration of cathecholamines in 24 (67%). Three venous thromboembolic complications occurred in the ICU (1.7%) and one during follow-up. Only one patient presented thrombocytosis at the time of diagnosis. Despite the fact that patients with thrombocytosis had a greater severity of illness, the ICU mortality was comparable among patients with and without thrombocytosis (8 vs 14%, P=0.34). CONCLUSIONS: Reactive thrombocytosis is a common finding after severe trauma and was found to be associated with a better survival than predicted by severity of illness score. Unless additional risk factors are present, reactive thrombocytosis is not associated with an increased risk of thromboembolic events.

[Extemporaneous analysis of myocardial performance by a programmable automatic dynamometer]. / Analyse extemporanée de la performance myocardique par dynamomètre automatique programmable.

This article describes a biophysical investigation to determine the physiological integrity of isolated cardiac fibers obtained during surgery. Immediate biopsy of myocardium can be analysed dynamically in various physiological conditions using an intelligent dynamometer controlled by an "APPLE II" microcomputer generally in less than fifteen minutes. Multiple tests including pharmacological and electrical properties of fibers can now be done with this cardiac analyser. Primary investigations on heart diseases show the importance of the method for evaluation of heart necrosis.

Surgical techniques for treatment of bacterial endocarditis of the mitral valve.

Bacterial endocarditis of the mitral valve appears to be much less common than bacterial endocarditis of the aortic valve. One of the main etiologic factors is the presence of degenerative lesions of the mitral apparatus, ballooning or mitral floppy valve. The surgical anatomy of the lesions is described: vegetations, perforations, rupture of chordae tendinae, abscess of the mitral ring observed in the isolated mitral endocarditis, mitral-aortic dislocation, abscesses and aneurysms of the mitral-aortic fibrosa and jet lesions on the anterior mitral leaflet. In the isolated primitive mitral infective lesions, all the technical skills are directed toward the prevention of the perivalvular leakage of the prostheses. Special procedures are described for the management of the abscesses of the mitral ring. In patients with mitral-aortic lesions, the main problem is treatment of the dislocation of the annuli or aneurysms of the mitral-aortic fibrosa. Despite technical advances, the surgical prognosis of the mitral endocarditis remains severe. In a personal series, the authors recorded a mortality of 12% in isolated mitral cases and 42% in the combined mitral-aortic patients. Early surgical treatment remains the most significant factor in decreasing the fatality of such lesions.

[Cor triatriatum. Anatomical forms and surgical treatment of 6 consecutive cases]. / Coeur triatial. Formes anatomiques et traitement chirurgical de 6 cas consécutifs.

Six cases of cor triatriatum documented and operated on at Henri-Mondor hospital between 1980 and 1984 are reported. Ages at the time of surgery ranged from 8 months to 57 years. Four of the 6 patients presented with pulmonary hypertension. Anatomic types consisted of 4 diaphragmatic types and 2 more complex malformations. Associated lesions were present in all but one patients. They consisted mostly of interatrial defects (depending on their position with regard to the intra-atrial membrane, they play a determinant role in the symptomatology) and of a left superior vena cava (which might play a role in the embryogenesis of the malformation). Except for one early postoperative death, results of surgery were excellent for all patients, with a mean follow-up of 5 years. This series, compared with the literature, allows precising the embryologic and anatomic aspects of the malformation and the surgical techniques in complex types.

[Viability of new valvular homografts. Myth or reality?]. / La viabilité des nouvelles homogreffes valvulaires. Mythe ou réalité?

Use in cardiac surgery of aortic homografts as a valvular substitute is old and was specially developed in France by F. Fontan. In fact, these first allografts were non-viable and the results, in aortic position, were not better than current bioprosthesis. Renewed interest is related to the important notion of "viability" allowed by an immediate procurement (organ donors), preparation in nutrient medium RPMI with low doses of antibiotics and final storage at -196 degrees C (cryopreservation). We have reviewed our initial experience concerning 32 implanted homografts in children either in reconstruction of the right ventricular outflow tract (in many forms of congenital heart disease) or in aortic position. No mortality was observed. The only failure was due to an initial sizing mistake leading to an aortic valve replacement at 13 months. No late deterioration (mean follow-up: 12.5 months) was detected by echocardiography. These results seem to confirm other larger series (as O'Brien's, Brisbane, Australia). Biologic, histological and immunological assessments of "viable" homografts are discussed. The limits of the technique are reported.

Long-term evaluation of bioprosthetic valves: 615 consecutive cases.

From January 1975 to September 1983, 615 patients underwent valve replacement using 698 bioprosthetic valves for selected indications. This group represents the third of all patients having valve replacement during the same period. Children younger than 15 years were excluded. The mean pre-operative functional class was 2.9. The early mortality rate was less than 5% and the follow-up range 3 months to 9 years (3.2 yrs). The symptomatic improvement was attested by a mean post-operative functional class of 1.4. In a linear study the following rates of valve related complications were noted: thromboembolism 4.6%, endocarditis 2.5%, primary tissue valve degeneration 1.1%, paraprosthetic leak 2.5%. In an actuarial study, at 8 years, 83% of patients were free from any valve failure. The probability rates of complications were the following: thromboembolic events 8%, endocarditis 5%, degeneration 3%, reoperation 7%. The probability of survival at 8 yrs was 69% and the probability rates of late mortality were noted as follow: cardiac related mortality 27%, valve-related mortality 4%. Despite an expected increasing rate of degeneration, the results warrant the use of bioprostheses in a selected group of patients.