[Aid to the development of medicine in the emerging world: myths and realities]. / Aide au développement médical dans les pays émergents: mythes et réalités.

The diverse aspects of aid to development of medicine in the emerging world are discussed in the context of Switzerland, a non-colonial country. Emphasis is on the benefits of projects realised in the emerging countries, rather than the education of individuals coming to the developed countries.

Capacity building in cardiac surgery in emerging countries: an overview.

Cardiac surgery in the developed world is advancing rapidly towards extremely expensive and time-consuming technologies such as robotic surgery, whereas, at the same time, access to life saving treatment by simple cardiac surgery is denied to many patients in the emerging world. This widening gap of access to technologies in distinct parts of the world has been eloquently described by one of the foremost US cardiac surgeons, Dr James Cox, in his presidential address to the American Association of Thoracic Surgery in San Diego in May 2001. Dr Cox demonstrated the startling figures shown in the table below and pleaded for involvement of surgeons from the developed world in capacity building in the emerging countries.

[Innovations in the treatment of aneurysms of the ascending aorta]. / Nouveautés dans le traitement des anévrismes de l'aorte ascendante.

Numerous innovations conceming the difficult problems of ascending aortic surgery appear regularly in the literature. Two of these have been selected for this review because of the impact they have had on the treatment of aneurysms of the ascending aorta. These are the aortic valve sparing operations for root replacement and canulation of the right subclavian artery. the first is a modification of the Bentall-DeBono operation, avoiding the replacement of structurally normal valve leaflets and thus avoiding long term anticoagulation treatment. The safety of the procedure and the long term results are excellent. Subclavian canulation allows better cerebral protection when circulatory arrest is required and has simplified considerably surgery for both aortic dissections, ascending aorta and arch aneurysms.

Percutaneous transluminal angioplasty of right and left internal mammary artery grafts.

Four patients with recurrent severe angina and evidence of myocardial ischemia two to six months after surgical coronary revascularization have been submitted to percutaneous transluminal angioplasty of the distal insertion of internal mammary artery grafts or of the recipient vessel distal to it. These cases illustrate the feasibility and safety of transluminal angioplasty of right and left internal mammary artery grafts, using the mammary artery as a way of access.

Gastrointestinal complications after coronary artery bypass grafting.

Clinical variables were studied in 3129 patients undergoing coronary artery bypass grafting to identify patients at risk of abdominal complications and common etiologic factors in the development of such complications. Seventy-three gastrointestinal complications occurred (2.3%), with an overall mortality rate of 16.4% compared with a mortality rate of 3.4% for all patients undergoing bypass grafting (p < 0.001). Cholecystitis and intestinal ischemia were the most frequently encountered complications. Multivariate analysis demonstrated that preoperative hypertension, New York Heart Association classes III and IV, preoperative left ventricular ejection fraction less than 40%, age greater than 70 years, reoperation, and urgent operation as independently and significantly associated with gastrointestinal complications. In contradiction to previous reports, no significant correlation existed between gastrointestinal complications and cardiopulmonary bypass time, 99.8 +/- 35.8 versus 101.2 +/- 39.8 minutes. Perioperative myocardial infarction and immediate postoperative hypotension with low cardiac output necessitating substantial inotropic pharmacologic support or intraaortic balloon pumping were significantly more prevalent in patients who had gastrointestinal complications (all p < 0.001). Furthermore, multivariate analysis revealed that postoperative low cardiac output was a significant, independent predictor in the development of gastrointestinal complications of any kind after coronary artery bypass grafting. Postoperative splanchnic hypoperfusion could therefore be a common etiologic factor.

Right ventricular outflow obstruction after radiation therapy.

A unique case of radiation-induced heart disease associated with acquired right ventricular outflow obstruction is presented. Surgical management of this case is described.

Implantation of antibiotic-releasing carriers for treatment of recurrent prosthetic endocarditis.

A 26-year-old man had early recurrence of aortic prosthetic endocarditis with recurrent prosthetic valve dysfunction. Tertiary valve replacement with implantation of antibiotic-releasing carriers for local treatment of aortic root abscesses was performed successfully in this highly lethal condition.

Implantation techniques for the Hemopump.

Techniques for implantation of the Hemopump, an intraarterial, axial-flow circulatory assist device, are described. The Hemopump, which is currently undergoing clinical investigation, has been used successfully to treat patients experiencing profound left ventricular failure in a variety of clinical situations, including postcardiotomy shock, acute myocardial infarction, cardiac allograft rejection, and cardiac allograft failure.

How safe is coronary bypass surgery in the elderly patient? Analysis of 111 patients aged 75 years or more and 2939 patients younger than 75 years undergoing coronary artery bypass grafting in a private hospital.

AIM AND METHODS: Data from patients younger than 75 years (group I, n = 2939) and patients aged 75 years or older (group II, n = 111) who underwent isolated coronary artery bypass grafting (CABG) during a 9-year period (January 1984 to April 1993) were analyzed to determine comparative risk factors for morbidity, early and late survival, and functional outcome. RESULTS: Traditional risk factors (hypertension, hyperlipidemia, diabetes mellitus, and smoking) were significantly more prevalent in group II. The number of patients in New York Heart Association (NYHA) functional classes 3 and 4 before surgery was also significantly higher in group II (P < 0.001), but emergency operations were equally distributed between the groups. Left main-stem stenosis was more frequent in group II patients (P < 0.01), while the number of vessels involved and pre-operative left ventricular function did not differ. Both groups underwent a mean of 4.5 grafts. Internal mammary grafts were placed in 48.4% (1422/2939) in group I and 19.8% (22/111) in group II (P < 0.001). The overall peri-operative mortality rate did not differ between the groups (2.9% for group I and 2.7% for group II). Non-fatal peri-operative myocardial infarction, ventricular arrhythmias, post-extracorporeal circulation disorientation, and temporary renal insufficiency were more prevalent in group II patients (all P < 0.05). Emergency operations and re-operative CABG increased the peri-operative mortality in both groups. The 3-year survival rate was 93% and the 3-year cardiac event-free rate was 88% for the group II patients. Most of the elderly patients (98%) were in NYHA functional classes 1 and 2 at the end of the follow-up. CONCLUSIONS: Even if elderly patients have a slightly higher postoperative morbidity than younger patients, and an increased mortality if operated upon in an emergency, long-term survival and freedom from cardiac events are excellent and justify the continued performance of CABG in patients aged 75 years of age or more.

Is reoperative coronary artery bypass grafting in patients with poor left ventricular ejection fractions < or = 25% worthwhile?

AIM: This study aimed to investigate whether patients with very low left ventricular ejection fractions (LVEF) should be accepted for reoperative coronary artery bypass grafting (CABG). STUDY POPULATION: Between January 1990 and December 1993, 1681 patients underwent primary CABG and 308 (15.5%) reoperative CABG. One hundred and eight patients (5.4%) had an LVEF < or = 25%, 91 patients for primary CAGB (group I) and 17 for CABG (group II). The mean age of the patients was 62 years. Sex distribution and preoperative risk factors did not differ. Urgent operations were more frequently necessary in group II (P < 0.01). Mitral regurgitation was present in 49% of the group I patients and 18% of the group II patients (P < 0.05). Pulmonary artery hypertension was observed in 24% of group I patients, but in only 6% in group II patients. The mean LVEF was 21% and left ventricular end-diastolic pressure 18 mmHg, without between-group differences. All patients had significant two- or three-vessel disease (stenosis > or = 70%). An average of 4.5 grafts per patient were performed. Mitral valve surgery was not performed in any of the patients. RESULTS: The postoperative mortality was significantly higher in reoperative CABG patients (group II; 23.5%) than in group I patients (12.1%; P < 0.05), whereas the incidence of non-fatal myocardial infarction did not differ. The incidence of postoperative complications did not differ between the groups, except for transient renal failure, more frequently encountered in group II (P < 0.05). After an average follow-up of 18 months, the New York Heart Association (NYHA) class and the LVEF were significantly improved in both groups (NYHA class from 3.5 to 1.8 and LVEF from 21% to 45%; P < 0.001). The mitral regurgitation had improved or completely disappeared at the end of follow-up in all patients in both groups. CONCLUSIONS: Our results suggest that patients with left ventricular ejection fraction < or = 25%, angina and significant two- or three-vessel coronary artery disease should not categorically be refused for reoperative CABG. Careful patient selection is necessary because of an increased operative risk.

Surgery of the ascending aorta. Analysis of risk factors and results of 30 operations in a private institution.

Replacement of the ascending aorta for aneurysm or dissection remains a complex challenge for cardiac surgeons. Between January 1984 and December 1993, 30 patients have had simultaneous resection of the ascending aorta and aortic valve replacement. Sixteen of them had composite graft replacement of the ascending aorta and the aortic valve with a modified Bentall's technique (Group I). Fourteen patients had supracoronary artery aortic resection and aortic valve replacement (Group II). The mean age was 50.1 +/- 15.3 years (range 23-76). There were 22 men and 8 women. Five patients (16.7%) had aortic dissection, six were operated on an emergency basis. Concomitant coronary artery disease was more frequently seen in Group II (5 patients) than in Group I (1 patient), p < 0.05. Other preoperative patient characteristics did not differ. The overall perioperative mortality was 16.7% (5/30), none of them due to technical complications during surgery. Four patients died in Group I and 1 in Group II (n.s.). Non-fatal myocardial infarction was diagnosed in 1 patient (Group I) and only one neurological complication occurred (Group I), while reexploration for bleeding was performed in 4 cases (13.3%). Four patients in Group I and two in Group II had postoperatively low cardiac output, two of them necessitating intraaortic balloon pump insertion. 43% of the patients had no perioperative complications. At the end of follow-up (n = 25), average 6 months (range 1-52 months), twenty-two survivors (22/25 or 88.0%) were in NYHA functional class 1. Simultaneous ascending aortic aneurysm repair and aortic valve replacement can be accomplished with an acceptable mortality and little morbidity.

Should a mild to moderate ischemic mitral valve regurgitation in patients with poor left ventricular function be repaired or not?

In recent years coronary artery bypass grafting (CABG) has been extended to include patients with very low left ventricular ejection fractions (LVEF), also frequently with co-existing mild to moderate mitral valve regurgitation (MR). The question is, should such a MR be corrected simultaneously with a myocardial revascularization or not? Between January 1989 and November 1994, 56 patients with preoperative LVEF < or = 25% and echocardiographic evidence of co-existing MR (Grade I: 41%, II: 46%, III: 13%) underwent primary CABG. None of them had simultaneous mitral valve surgery. Twenty-nine patients (52%) had a pulmonary artery pressure (PAP) > 40 mmHg. The mean preoperative LVEF was 17.9 +/- 4.6 (10-25), mean PAP 44.2 +/- 16.1 mmHg. An average of 4.5 +/- 1.5 grafts/patient were placed and five patients had simultaneous repair of a post-infarction left ventricular aneurysm. The overall mortality was 3.6% (2/56). Transient post-operative low cardiac output syndrome occurred in 16 patients (29%). Twenty-one patients (38%) had no postoperative complications at all. The 54 hospital survivors were followed up over a mean period of 12 months (3-36 months). There was one death (eight months postoperatively) and two graft occlusions, not requiring reoperation. At the end of the follow up echocardiography showed that 50 patients (93%) had no (31 patients) or only a very mild Grade I MR (19 patients). Four patients had Grade II MR, none of them requiring mitral valve surgery. All patients improved their NYHA functional class, from 3.4 +/- 0.8 to 1.9 +/- 0.7 and LVEF from 17.9 +/- 4.6 to 44.2 +/- 7.4 (p < 0.001). Coronary artery bypass grafting is a possible treatment for patients with very low LVEF, provided the patient has a two- or three-vessel disease with significant coronary artery stenosis (> 70%) and angina. Mortality and morbidity are low. Moderate co-existing MR (Grade I-III) seems to normalize after myocardial revascularization and should not be surgically corrected therefore at the primary operation.

Reactive thrombocytosis after coronary bypass surgery. An important risk factor.

Reactive thrombocytosis (RT) has earlier been reported to occur as a response to various situations and conditions, such as post-splenectomy, hematopoietic disorders, major trauma and operations, neoplasms and inflammations. In cardiac surgery the main interest has focused on thrombocytopenia that occurs after cardiopulmonary bypass (CPB) and the risk of postoperative bleeding, rather than the possibility of a late occurrence of RT as a risk factor for thrombotic complications after coronary artery bypass grafting (CABG). Between 1989 and 1992, on routine blood examinations we noticed a group of CABG patients (n = 297, Group II, 19.5%) that, 1 week after operation, showed thrombocytosis with significantly increased platelet count (521 +/- 96 x 10(3)/mm3) compared to patients with normal platelet counts (Group I, n = 1521, 185 +/- 125 x 10(3)/mm3); P < 0.001. Patient characteristics, coronary angiography findings, operative data and perioperative complications were analyzed for the two groups. There were significantly more patients with hyperlipidemia, smoking and previous myocardial infarction in Group II than in Group I; P < 0.05. Age, sex, clinical characteristics, angiography findings and operative data did not differ between the groups. There were no differences in postoperative bleeding or the need of transfusion between the groups. However, Group II (RT) patients had significantly more postoperative myocardial infarctions, 4.4% compared to 0.7% Group I; P < 0.001. Early symptomatic vein graft occlusion (0-7 days postoperatively) was not different between the groups, while there were significantly move late symptomatic vein graft occlusions (7-60 days postoperatively) in Group II (RT) 4.4% than in Group I 1.1%; P < 0.001.(ABSTRACT TRUNCATED AT 250 WORDS)

Open chest and delayed sternal closure after cardiac surgery.

OBJECTIVES: Open chest (OC) and subsequent delayed sternal closure (DSC) has been described as a useful method in the treatment of the severely impaired heart after cardiac surgery. METHODS: Prolonged open chest was used in 142 to 3373 adult cardiac operations (4.2%) between January 1987 and December 1993. The indications were: hemodynamic compromise (121), intractable bleeding (9) and arrhythmias (12). Delayed sternal closure was carried out in 123 of 142 patients at a mean of 2.0 +/- 1.4 days (range 0.5-8 days). Open chest and DSC were used proportionally more frequently after combined cardiac surgery (28/293, 9.6%) than after coronary artery bypass grafting (CABG) alone (108/2891, 3.7%) or valve operation (6/230, 2.6%). RESULTS: Ninety-seven of the 123 who had DSC (78.9%) survived and were discharged an average of 8.6 +/- 4.2 days after closure. Fourty-five patients died: 19 before DSC and 26 after this method. Mortality was related to indications for OC: when the indication was low cardiac output the mortality was 38.6%, for hemodynamic collapse on closure 0%, diffuse bleeding 33.3% and arrhythmias 27.3%. Delayed sternal closure in patients without intraaortic balloon pump support was more likely to be successful (mortality rate 4/25, 16.0% versus 35/76, 46.3%, P < 0.01). Superficial sternal wound infection occurred in 2 of 123 (1.6%) patients after DSC, mediastinitis in 1 (0.8%) and sternal dehiscence in 3 (2.4%) patients, which does not differ from a control population that had primary sternal closure. The follow-up of 97 survivors at an average of 28 +/- 4 months revealed an improvement of NYHA class by 1.4 +/- 0.4. There were 16 deaths (13 cardia-related) during the follow-up period and 3 redo CABG. One case of sternal osteomyelitis occurred without any other late sternal morbidity. CONCLUSIONS: This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias. It can be performed without increased sternal morbidity. Long-term results are also encouraging.

Risk factors for development of accelerated coronary artery disease in cardiac transplant recipients.

Allograft coronary artery disease (CAD) is the major determinant of long-term survival following heart transplantation (HTx). In a group of 210 heart transplant recipients, we diagnosed CAD in 54 (27.1%) by coronary angiography, postmortem examination or examination of the transplanted heart at the time of retransplantation. Retrospective analysis of potential risk factors for the development of CAD was performed for both immunological (rejection pattern, immunosuppressive therapy, cytomegalovirus [CMV] infection), and nonimmunological (hyperlipidemia, smoking, hypertension, diabetes mellitus, obesity) risk factors. The total number of rejection episodes correlated significantly with the occurrence of CAD (P less than 0.05), showing that patients who experienced two or more rejection episodes had an incidence of CAD of 40%, as opposed to a 23% incidence in patients who experienced no rejection. A composite rejection score derived from multivariate regression analysis of the severity, frequency, and timing of acute cardiac rejection episodes was found to correlate with the development of CAD (P less than 0.05). Postoperative arterial hypertension also correlated significantly with the onset of CAD (P less than 0.01), with a 92.6% incidence of hypertension in the group with CAD versus 76.3% in the group without CAD. Smoking after transplantation correlated significantly with the occurrence of CAD (P less than 0.05). There was no significant correlation with other analyzed factors in this group of patients. In this review, the development of CAD after heart transplantation correlated with treated allograft rejection. Aggressive treatment of hypertension and cessation of smoking may contribute to alleviation of this serious complication.

Effect of low left ventricular ejection fractions on the outcome of primary coronary by-pass grafting in end-stage coronary artery disease.

Advanced ischemic heart disease (HID) with very low left ventricular ejection fraction (LVEF), pulmonary hypertension (PHT) with or/without left ventricular aneurysm (LVA) are criteria for defining end-stage coronary artery disease (ESCAD). Coronary artery by-pass grafting is often denied to these patients. Between January 1990 and December 1993, 91 patients with ESCAD, significant 2 or 3-vessel disease (stenosis > or = 70%) and LVEF < or = 25% underwent primary CABG at our institutions. The mean age was 62.5 +/- 8.0 years (41-81), 89% were men. Eighty-one patients were in preoperative NYHA (New York Heart Association) functional class 3 and 4. Mean LVEF was 21.3 +/- 3.8% (10-25). Mitral regurgitation (MR) was present in 39/91 (43%). The systolic pulmonary artery pressure (PAP) was 33.2 +/- 17.1 mmHg (11-75) and the wedge pressure was 19.0 +/- 10.8 mmHg (5-47). Twenty-two patients had significant PHT with a systolic PAP > or = 40 mmHg. The overall perioperative mortality was 14.3% (13/91). Low postoperative cardiac output occurred in 33 patients, requiring intraaortic balloon support in 13. Gastrointestinal complications occurred in 6 patients and neurological events in one. Fifteen patients had additional left ventricular aneurysm repair. There was a good correlation between LVEF and PAP (r = 0.782). Surprisingly, in a subset of patients with preoperative PHT and LVEF < or = 25% the mortality rate was only 4.6% (1/22). Other perioperative complications did not differ.(ABSTRACT TRUNCATED AT 250 WORDS)

A patent internal mammary artery graft decreases the risk of reoperative coronary artery bypass surgery.

In order to evaluate the potential risks of a patent internal mammary artery bypass at reoperative coronary artery bypass grafting, we have reviewed the records of 233 consecutive patients undergoing reoperative coronary artery bypass grafting between 1 January 1991 and 31 December 1993, including 209 patients having an occluded mammary graft or no mammary graft (Group I) and 24 patients having a patent mammary graft (Group II). With regard to preoperative patient characteristics, the only significant differences between the groups were: Group II patients had a higher preoperative left ventricular ejection fraction than did Group I patients (63.7% +/- 8.9% vs. 52.1% +/- 10.1%, p < 0.001); and Group II patients had received fewer grafts per patient than had patients in Group I (2.2 +/- 1.1 vs 3.6 +/- 1.4 grafts per patient, p < 0.001). There were no entry injuries to the grafts or to the heart in either of the groups. No perioperative mortality was encountered in Group II, while 11 patients died in Group I (p < 0.05). Group II had a significantly higher incidence of reexploration for post-operative bleeding, whereas Group I had a significantly higher incidence of low postoperative cardiac output. The incidence of all other perioperative complications did not differ between the groups. The results of this study support the use of mammary grafts even in patients who are likely to need repeat coronary artery bypass grafting and certainly does not disqualify such patients from a 2nd operation.

Mitral regurgitation in patients with coronary artery disease and low left ventricular ejection fractions. How should it be treated?

In recent years, coronary artery bypass grafting has been extended to include patients with very low left ventricular ejection fractions. Should concomitant mitral valve regurgitation be corrected simultaneously? Between January 1990 and July 1994, 43 patients with preoperative left ventricular ejection fractions < or = 25% and echocardiographic evidence of concomitant mitral valve regurgitation (grade I, 18 patients; II, 19 patients; and III, 6 patients) underwent primary coronary artery bypass grafting. None of these patients underwent simultaneous mitral valve surgery. Twenty-four patients (56%) had pulmonary artery pressures > or = 40 mmHg (pulmonary hypertension). The mean preoperative left ventricular ejection fraction was 18.7% +/- 4.4% (range, 10% to 25%), and the mean pulmonary artery pressure was 45.6 +/- 15.8 mmHg. The average of number of grafts per patient was 4.5 +/- 1.5. Five patients underwent simultaneous repair of a left ventricular aneurysm. The hospital mortality rate was 4.7% (2/43). Transient low cardiac output occurred postoperatively in 13 patients (30%). Sixteen patients (37%) had no postoperative complications. The average follow-up of the 41 hospital survivors was 6 months (range, 1 to 32 months). One patient died 8 months after surgery for an overall mortality rate of 7%. Another 2 patients had graft occlusions that did not require reoperation. In the 40 surviving patients, follow-up echocardiography revealed that 37 patients (93%) had either no mitral valve regurgitation or only very mild mitral valve regurgitation (grade I). Three patients had grade II mitral valve regurgitation, but none required mitral valve surgery. The New York Heart Association functional class improved significantly in all hospital survivors (from 3.4 +/- 0.6 to 1.7 +/- 0.7; p > 0.001), and left ventricular ejection fractions rose from 19.0% +/- 4.6% to 42.0% +/- 8.3%. Coronary artery bypass grafting is possible in patients with very low left ventricular ejection fractions who present with 2- or 3-vessel disease, significant coronary artery stenoses (less than or equal 70%), and angina. The mortality rate is acceptable and morbidity is low. If there is no rupture of papillary muscle or chordae, concomitant ischemic mitral regurgitation (grades I through III) seems to return to normal after coronary artery bypass grafting and, therefore, does not need to be corrected surgically during the primary operation.

"Acquired" left ventricular-to-right atrial shunt (Gerbode defect) after bacterial endocarditis.

We present, with echocardiographic and intraoperative findings, a rare case of left ventricular-to-right atrial communication (Gerbode defect) after endocarditis associated with Staphylococcus aureus. (Tex Heart Inst J 1995;22:100-2)