Coronary artery revascularisation without extracorporeal circulation. Indications and results

OBJECTIVE

Coronary artery revascularisation without extracorporeal circulation is a technique which can be performed in selected patients in need of a coronary artery bypass graft.

METHODS

Consecutive patients (210) underwent coronary artery bypass graft without extracorporeal circulation. Indications were high risk patients, or single coronary artery lesion. To predict perioperative mortality, preoperative risk factors were reviewed, and Parsonnet score was calculated.

RESULTS

There were seven deaths (3.3%), and univariate analysis revealed greater age, NYHA, and poor ejection fraction to be the only predictors of early mortality. Perioperative myocardial infarction included 15 patients (7.1%), most of them seen in the multiple bypass group (10/39, 26%). Patients were divided into low risk (Parsonnet score < 15) 155 patients with two deaths (1.2%), and high risk (Parsonnet score > 15) 55 patients with five deaths (9%). Complete revascularisation was performed in the low risk group, while in the high risk only the symptomatic vessel was bypassed and other angiographic lesions treated with postoperative angioplasty (10 patients). A total of 12 patients developed early postoperative angina (5.7%), 9 presented an anastomosis dysfunction which was treated by angioplasty (5) and surgery (4), and 188 patients (85.7%) did not receive transfusions while 190 patients (90.4%) did not need postoperative inotropes. Length of stay, operating room time, and medical costs were all significantly reduced.

CONCLUSIONS

Myocardial revascularisation without extracorporeal circulation can be performed with a low operative mortality, and minimal morbidity only in patients undergoing single bypass revascularisation. It can also be performed as part of a multiple revascularisation strategy in association with angioplasty in high risks patients.

Calcified embolus of the left coronary ostia after aortic valve replacement

A patient with a left coronary calcified embolus causing acute myocardial dysfunction immediately after aortic valve replacement is described. Prompt diagnosis by transesophageal echocardiogram was made, which led to removal of the embolus and a subsequent satisfactory course.

[Observatoire des Allergies Oculaires. National epidemiological survey of chronic (perennial) allergic conjunctivitis and/or keratoconjunctivitis seen in ophthalmology]

A second epidemiological ocular allergy survey was carried out by ophthalmologists during the winter of 94/95 in order to define the main characteristics of patients suffering from chronic, perennial allergic conjunctivitis or keratoconjunctivitis. From the data collected from a wide sample of 791 patients, we were able to describe the main symptoms and lesions related to chronic ocular allergy, its evolution and the allergens involved. Allergic symptoms (conjunctival redness, foreign body sensation, itching) are reported in 98.5% of patients. Non specific symptoms (burning, photophobia, blurred vision, ocular dryness) are reported in 3 patients out of 4. 40% of patients have perennial manifestations without any seasonal exacerbation while 1 patient in 2 suffers from a seasonal worsening. In 80% of the cases, the responsible allergens are domestic (house dust, miles), 60% of patients are affected by at least 2 allergens. Ophthalmic examination shows lesions of the tarsal conjunctiva (papillas, follicles) in 94% of the cases and corneal lesions in practically 50% of the patients. This epidemiological survey shows the necessity of having a rigourous clinical approach which includes a complete ophthalmological examination which is the only thorough means of assessing the allergic lesions and proposing the most suitable treatment for day to day ophthalmic practice.

[Closure of patent ductus arteriosus by video thoracoscopy in 282 children]

Closure of patent ductus arteriosus by video thoracoscopy is a standardised procedure. The authors report their experience of closure of patent ductus arteriosus by video-thoracoscopy from May 1991 to December 1995. The series included 282 patients divided into 3 groups according to age: under 6 months (78 patients, 27.6%), from 6 months to 4 years (135 patients, 42.88%) and over 4 years of age (69 patients, 24.6%) with an average weight of 12.6 kg (range: 1.2 to 65 kg). Symptomatic pulmonary hypertension was observed in 39 cases and 9 children had associated intracardiac malformations (ostium secundum: 3; ventricular septal defect: 5; abnormal pulmonary venous drainage: 1) which were not corrected. The technique consisted of placing two titanium clips in position under video-thoracoscopy to close the ductus. An echo performed immediately afterwards confirmed closure of the ductus. The main complications were: persistence of a shunt (4 cases) at the beginning of our experience requiring immediate reoperation by video-thoracoscopy in 3 cases and by thoracotomy in one case; left recurrent laryngeal nerve palsy in 6 cases (2.1%) with regression in 5 and persistence in one case; one case of postoperative chylothorax which regressed rapidly. There were no fatalities or haemorrhages and no blood transfusions were required in this series. The average operating time was 20 +/- 15 minutes and the duration of hospital stay around 48 hours when the patients were over 6 months old and 72 hours when less than 6 months of age. Video-thoracoscopic closure of patent ductus arteriosus is rapid, safe, economical, it provides excellent results and may be used in children of all ages.

[Contribution of multiplane transesophageal echocardiography in the study of mitral valve prostheses]

Many reports have confirmed the value of transoesophageal echocardiography in the diagnosis of mechanical mitral valve prosthesis dysfunction: new biplane and multiplane probes seem to provide additional information in the assessment of cardiac disease. The aim of this study was to quantify the additional value of these new probes in the assessment of mitral valve prostheses. Seventy-five mitral valve prostheses were assessed with the multiplane probe, 45 normal bileaflet prostheses, 17 with regurgitant dysfunction and 12 with non obstructive thrombi and/or strands, and one with a blocked leaflet. In order to compare the respective values of monoplane, biplane and multiplane probes, the recordings were performed at 0 degrees, 90 degrees and from 0 degrees to 180 degrees in continuous sweep mode through the scanning plane. Globally, with the monoplane assessment, it was only possible to visualise both leaflets simultaneously in 13% of cases. The majority of prostheses was correctly analysed between 60 and 100 degrees. This was of paramount importance for the diagnosis of blockage of one leaflet. With respect to para-prosthetic valve regurgitation, the transverse view allowed visualisation of the lateral and paraseptal annular regions. The addition of a longitudinal view allowed visualisation of anterior and posterior regurgitant jets: the supplementary views provided by the multiplane probe allowed detection of small regurgitant jets in the diagonal planes between the longitudinal and transverse views. The multiplane probe offers the possibility of identifying the precise origin of the jet and helps quantification and peroperative localisation of its position. Small, non-obstructive thrombi and strands are better seen using a multiplane probe, especially when of small size. Therefore, multiplane transoesophageal echocardiography improves the assessment of mitral valve prostheses, the majority of diagnoses being, however, accessible with biplane probes.

Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases

Video-assisted thoracoscopic surgical interruption for patient ductus arteriosus is a well-standardized procedure already described. We present our entire series of such cases, from the first case (performed on Sept. 5, 1991) to March 1, 1995. Two hundred thirty patients in a variety of age groups underwent video-assisted interruption: younger than 6 months (70 patients, 30%), 6 to 48 months (123 patients, 54%), and older than 48 months (37 patients, 16%). The mean weight was 12.6 kg (range 1.2 to 65 kg). Thirty-nine patients had symptomatic pulmonary hypertension. Associated intracardiac anomalies included atrial septal defect (three), ventricular septal defect (five), and anomalous pulmonary venous return (one). All patients underwent video-assisted interruption of the patient ductus arteriosus with two titanium clips. Closure was evaluated by postoperative echocardiography before extubation. Five patients had a persistent patent ductus after video-assisted interruption, all early in our experience and related to insufficient dissection resulting in inadequate clip placement. Four patients had successful immediate clip repositioning (three by video-assisted interruption and one by thoracotomy). Subsequent echocardiography revealed persistent closure in these patients. A persistent patent ductus arteriosus with minimal flow was discovered in one patient without symptoms after discharge. Recurrent laryngeal nerve dysfunction was noted in six patients (2.6%, five transient and one persistent). There were no deaths, hemorrhages, transfusions required, or chylothoraces in this series. Mean operative time was 20 +/- 15 minutes, and hospital stay averaged 48 hours for patients younger than 6 months and 72 hours for patients older than 6 months. This is a safe, rapid, cost-effective technique that results in excellent results and a shortened hospital stay. Video-assisted interruption represents the technique of choice for closure of a patient ductus arteriosus.

[In vitro evaluation of Dibie-Musset vena caval filter]

The Dibie-Musset (DM) vena caval filter was evaluated on a hydraulic test bench reproducing flow conditions in the inferior vena cava: pressure, flow, viscosity, diameter and elasticity of the conduit. The results were compared with those obtained with the Greenfield filter (GF). In addition to classical measurements (captation and loss of load) we measured the velocity profile with a Doppler ultrasonic probe proximal and distal to the filter to study flow conditions before and after embolisation of clots. In order to circumvent the difficulties encountered with the use of real thrombi, chemical gels with visco-elastic properties, evaluated by viscosimetry, similar to those of blood clots, were used. Clots 45 mm long and 4 mm diameter were injected in several series of measurements. The DM filter was stable and did not migrate. In the horizontal position (flexible conduit) the DM filter was significantly more effective than the GF for less than 5 clots injected successively. The filtration capacity of both filters decreased with the number of clots captured. In the vertical position (rigid conduit), when there are less than 5 clots injected the two devices were perfectly effective. There was no significant difference between the two filters when 10 clots were injected. The loss of load resulting from the presence of the filter and clots was greater with the DM filter because of the greater captation capacity. However, the velocity profile distal to the filter was less disturbed with the DM filter because there was a more uniform distribution of the clots captured over the surface of the filter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous caval filter Dibie-Musset "DM". Results of animal experiments]

AIM

a 7 F percutaneous cava filter was achieved, developed and tested in a goat. Thanks to its double-spiral original form, it is possible to place and remove it atraumaticaly and percutaneously. PRINCIPLES OF THE FILTER: its diameter, larger than the lower vena cava's (LVC) leads to a flattening of the venous lumen whose flow is intersected by the filter turns, thus creating a netting effect.

CASE-REPORT

during 28 months, 40 filters were introduced under fluorscopy in 20 goats. Thanks to 16 embolizations, it was possible to test the effectiveness of the filter against small emboli, with simultaneous cavography and pulmonary angiography in 4 cases. 29 filters were removed by jugular and femoral track, from D0 to D14. 12 goats were sacrificed to investigate histologicaly and macroscopicaly the LVC and control the biocompatibility from the 8th to the 385th day. Clinical and radiological supervision lasted more than one year for 3 goats.

RESULTS

the size of the filter (30, 35, 40 mm) is chosen from the LVC diameter measured by cavography. 30 filters were introduced via jugular vein, 10 via femoral vein. These filters were introduced by catheter 7F thanks to an applicator and placed in correct position in the LVC. RELIABILITY OF THE FILTER: easy percutaneous introduction 7F. Once installed, the filters flatten the LVC; this process is automatically confirmed by cavography, and by scanning in 4 cases. EFFECTIVENESS AGAINST EMBOLI: out of 16 cases, 2 partial failures were observed at the beginning of the experiment (one spiral-fitted filter). Its effectiveness was optimized thanks to the addition of a second spiral which allowed the blocking of over-2 mm clots. PERCUTANEOUS REMOVAL: during the initial removals, partial failures were due to the fragility of the filter and the inflexibility of the extracting material. Successive changes of the shape and the alloy of the filter as well as the development of catheters and extracting materials have led to a sufficient reliability to remove (D0 to D14) the filter in security, by percutaneous tract (9 jugular, 9 femoral) before its clamping on the LVC, on the 15th day. INNOCUOUSNESS: both biological supervision and anatomo-pathological investigation have showed the good tolerance of the filter. In local areas, this atraumatic filter does not wound nor perforate the LVC wall. Histologically, a thickening of the intima is observed. The positive results of this experiment led us to start clinical trials of "DM" filter in human beings.

Percutaneous double balloon valvuloplasty for stenosis of porcine bioprostheses in the tricuspid valve position: a report of 2 cases

The feasibility and results of percutaneous double balloon valvuloplasty were evaluated in 2 patients with stenosis of porcine bioprostheses in the tricuspid valve position. The procedures were performed with a Trefoil 3 x 10 and a 15 mm balloon. Long inflations (4 and 3 minutes) were well tolerated. A significant immediate increase in the valve area, without significant valvular regurgitation, was achieved in both cases, from 0.65 to 1.15 cm2 in case 1 and from 0.9 to 1.65 cm2 in case 2. Both patients required valve replacement during the follow-up, at 14 and 21 months. There was no restenosis, but echocardiography showed right atrial thrombosis in case 1. Progressive restenosis with peripheral edema and increase of the mean doppler gradient occurred in case 2. The procedure is feasible, safe, and well tolerated. It provides significant immediate hemodynamic improvement, but it should be considered as a palliative technique since a normal valve area can not usually be obtained and a restenosis is likely to occur at midterm follow-up.

[Value of early systematic postoperative transesophageal echocardiography in mitral valve replacements. A prospective study of 50 patients]

The aim of this study was to assess the value of routine transoesophageal echocardiography in the early postoperative period after mitral valve replacement. The authors report their experience in 50 consecutive operated patients (43 mechanical and 7 bioprostheses) investigated routinely by this method in the postoperative period in the surgical unit. Abnormal findings were observed in 36% of cases (18 patients): trans-prosthetic leaks (8 cases) and thrombosis (10 cases) in 2 bioprostheses and 8 mechanical prostheses; in 3 cases this led to haemodynamic dysfunction but in 7 cases the thrombus had no influence on the trans-prosthetic pressure gradient. No predisposing factor could be identified (spontaneous contrast, left atrial volume, left ventricular function, poor anticoagulation, blood clotting abnormalities). No abnormality of the mobile components of the prosthesis was observed at radioscopy. The outcome with heparin therapy was favourable with disappearance of the thrombi in 6 cases; the thrombi did not regress in 4 patients on heparin: 2 patients underwent thrombolytic therapy with a complete cure in 1 case and a severe embolic complication in the other; in 2 cases, the thrombus was so big that the patients were reoperated. Systematic early postoperative transoesophageal echocardiography before discharge from the surgical unit would seem to be necessary after early mitral valve replacement: it allows diagnosis of asymptomatic thrombosis which has an important emboligenic potential. The management of these thromboses remains controversial, but the poor natural outcome in cases of large thromboses should lead to referral for early reoperation.

Mediastinal infection after cardiac operation. A simple closed technique

From March 1984 to March 1987, a simple closed method, previously described for the treatment of osteomyelitis after orthopedic operations, was used to treat deep sternal infection in 11 patients. The basis of this technique is, after meticulous débridement of the wound, to drain all the infected areas with small catheters connected to a bottle inside of which a strong (700 mm Hg) negative pressure is created (Redon drainage device). The method does not require irrigation. The maximum duration of the drainage was 24 days and complete recovery was obtained in all patients without further surgical treatments. The comfort of the patients was optimal.

Anatomic repair of anomalies of ventriculo-arterial connection (REV). Results of a new technique in cases associated with pulmonary outflow tract obstruction

From November 1980 to November 1986, 63 patients aged 4 months to 13 years (mean 3.4 years) underwent repair of anomalies of ventriculo-arterial connection with ventricular septal defect and pulmonary outflow tract obstruction, using a technique (REV) first described by us in 1982. The selection of patients was based on preoperative criteria, namely the measurement of the distance between the tricuspid and the semilunar valves. These measurements enabled us to select from patients with an abnormal ventriculo-arterial connection, those in whom the anomaly could be repaired by intra-ventricular partition alone. In the remaining cases, REV was indicated in the presence of pulmonary stenosis. The principles of the technique are: (1) resection of the infundibular septum creating a large, direct and subarterial communication between the left ventricle and the aorta; (2) construction of a straight left ventricle to aorta tunnel by intraventricular partition; (3) direct anastomosis of the pulmonary trunk to the right ventricle. There were 12 hospital deaths (19%). The mean follow-up was 32 months. One patient died suddenly 1 year after repair. Six patients required reoperation. All survivors are in NYHA class I, except for 3 patients who are in class II. No stenosis of the left ventricular outflow tract was found but 5 patients had a significant pressure gradient at the pulmonary outflow tract level. Our present experience suggests that in properly selected patients, REV allows anatomic repair in a wide variety of anomalies of the ventriculo-arterial connection associated with VSD and pulmonary outflow tract obstruction with an acceptable rate of mortality and morbidity.

[Atrial septal defect type ostium secundum at the age of 40 or more. Apropos of 86 cases with hemodynamic exploration]

The authors propose a haemodynamic classification for ASD, taking into account the very frequent drop in systemic blood pressure which is observed in this disease in elderly people. The authors examine the clinical signs and the clinical course in terms of this haemodynamic classification and they stress the mitral abnormalities and the arrhythmias. 56% of patients were followed up for a mean of 6 years for non-operated patients and almost 10 years for operated patients. The pathophysiology of ASD is discussed. It appears to be very dependent on left ventricular function. The operation needs to be discussed in terms of the haemodynamic findings, even in elderly subjects and in almost asymptomatic subjects.