Short acting intravenous beta-blocker as a first line of treatment for atrial fibrillation after cardiac surgery: a prospective observational study

Post-operative atrial fibrillation (POAF) defined as a new-onset of atrial fibrillation (AF) following surgery occurs frequently after cardiac surgery. For non-symptomatic patients, rate control strategy seems to be as effective as rhythm control one in surgical patients. Landiolol is a new highly cardio-selective beta-blocker agent with interesting pharmacological properties that may have some interest in this clinical situation. This is a prospective, monocentric, observational study. All consecutive adult patients (age >18 years old) admitted in the intensive care unit following cardiac surgery with a diagnosed episode of AF were eligible. Success of landiolol administration was defined by a definitive rate control from the beginning of infusion to the 72th h. We also evaluated rhythm control following landiolol infusion. Safety analysis was focused on haemodynamic, renal and respiratory side effects. From 1 January 2020 to 30 June 2021, we included 54 consecutive patients. A sustainable rate control was obtained for 49 patients (90.7%). Median time until a sustainable rate control was 4 h (1, 22). Median infusion rate of landiolol needed for a sustainable rate control was 10 µg/kg/min (6, 19). Following landiolol infusion, median time until pharmacological cardioversion was 24 h. During landiolol infusion, maintenance of mean arterial pressure target requires a concomitant very low dose of norepinephrine. We did not find any other side effects. Low dose of landiolol used for POAF treatment was effective and safe for a rapid and sustainable rate and rhythm control after cardiac surgery.

[Pericardial foreign body: an unusual cause of chest pain in children]

Penetrating thoracic trauma by a needle or pin is rarely described in children. Localization of the needle may sometimes be difficult. The needle can migrate from the entrance site into many organs with time and cause little initial morbidity. We describe the case of a 14-year-old male patient with a sewing needle accidentally inserted through the chest wall. The foreign body had migrated spontaneously to the pericardium. A computed tomography scan of the chest is needed to determine the location of the needle and show any complications. Pericardium foreign bodies are dangerous and need electrocardiography and cardiac ultrasound before treatment. Removal of the needle by thoracotomy or thoracoscopy is indicated.

[Evaluation of the renal function in cardiac surgery with CPB: role of the cystatin C and the calculated creatinine clearance]

OBJECTIVES

The evaluation of the renal function in cardiac surgery is difficult. The gold standard remains the creatinine clearance in clinical practice. Cystatin C was recently proposed in order to evaluate the renal function. The aim of our study was to evaluate the cystatin C in cardiac surgery with CPB.

PATIENTS AND METHODS

After informed consent and ethical committee agreement, 60 patients operated in cardiac surgery with CPB were prospectively included. Cystatin C,measured and calculated (Cockcroft and MDRD methods) creatinine were compared with the Student t-test and with the Bland and Altman method. p<0,05 was considered as a significant threshold.

RESULTS

The reproducibility of the calculated creatinine clearance was better when the urinary collecting time was below 400 minutes. The estimation of the creatinine clearance by the Cockcroft and MDRD methods is better when the clearance is low. A significant correlation between the creatinine clearance and the cystatin C does exist, but the correlation coefficient was low. In case of acute renal dysfunction, the increase of the creatinine occurred earlier than the increase of the cystatin C.

CONCLUSION

In cardiac surgery with CPB, the evaluation of the renal function was not improved by the cystatin C.

Cardiac output measurements in off-pump coronary surgery: comparison between NICO and the Swan-Ganz catheter

BACKGROUND

The aim of this prospective study was to compare continuous cardiac output measurements of the non-invasive cardiac output system (NICO) with the pulmonary artery catheter during off-pump coronary bypass surgery.

METHODS

Twenty-two patients enrolled for off-pump coronary surgery received both a pulmonary artery catheter and a non-invasive cardiac output system for measurement of cardiac output. Data were compared by the Bland-Altman method to calculate the degree of agreement and to analyse if a significant difference existed between the two methods of cardiac output measurements.

RESULTS

Perioperatively, the non-invasive cardiac output underestimated cardiac output, but postoperatively overestimated it. The limits of agreement were larger during surgery compared to the postoperative period (-3.1; +2.5 vs. -1.4; +2.2 L min(-1)). Perioperatively, cardiac output measured with the pulmonary artery catheter varied from 0.5 to 7.5 L min(-1) (mean 3.6 L min(-1)) and with the non-invasive cardiac output from 0.5 to 8.4 L min(-1) (mean 3.9 L min(-1)). Postoperatively, these were 2.5-7.7 L min(-1) (mean 4.5 L min(-1)) and 2.3-8.4 L min(-1) (mean 4.9 L min(-1)), respectively.

CONCLUSION

During off-pump cardiac surgery, the non-invasive cardiac output reliably measures cardiac output and does it more rapidly than a pulmonary artery catheter and may be more useful in order to detect rapid haemodynamic changes.

Rupture de l'auricule droite après traumatisme fermé abdominal

If the cardiac injuries are frequent after closed chest traumatism, the cardiac injuries after abdominal closed traumatism are unusual but serious. We report the case of a right auricular rupture associated with a liver injury after a closed abdominal traumatism. The diagnosis was suspected on the TDM and confirmed by echocardiography. An emergency sternotomy was performed due to sudden haemodynamic instability. The initial clinical signs are often misleading. However the diagnosis must be made quickly and the treatment begun without delay.

[Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases]

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

Coronary artery reconstruction for extensive coronary disease: 108 patients and two year follow-up

BACKGROUND

Surgical coronary artery reconstruction for diffuse coronary disease is described and assessed.

METHODS

A long arteriotomy, internal thoracic artery graft, and exclusion of atheromatous plaques from the coronary lumen are the bases of the technique. One hundred eighteen reconstructions were performed in 108 patients with a mean age of 59 years. Stable angina was present in 62% of patients and unstable angina in 22%. Sixteen percent had had a recent myocardial infarction. The reconstructions involved 94 left anterior descending coronary arteries, 17 marginal, 5 diagonal, and 2 right coronary arteries.

RESULTS

The perioperative mortality rate was 3.7% (4 patients). The rate of perioperative myocardial infarction was 6.3%. Mean follow-up was 29 months (standard deviation, 10 months). Two patients were lost to follow-up. Ninety patients were free from angina and cardiac-related events. Five patients sustained a myocardial infarction, 3 were in congestive heart failure, 3 had class II angina, and 1 died of stroke. Seventy-four of the surgical coronary artery reconstructions have been angiographically evaluated (29 months): 94.6% of the internal thoracic artery grafts were completely patent, and 70 of the reconstructions were patent without restenosis. String signs and occlusions were present in two internal thoracic arteries each.

CONCLUSIONS

This technique allows revascularization of severely and diffusely diseased coronary arteries with encouraging results.

Surgical angioplasty with exclusion of atheromatous plaques in case of diffuse disease of the left anterior descending artery: 2 years' follow-up

OBJECTIVE

A new surgical technique of coronary artery angioplasty for diffuse and extensive lesions of the left anterior descending artery (LAD) is evaluated in this study.

METHOD

Ninety-four coronary artery reconstructions (CAR) using a new technique of angioplasty of the LAD were performed: mean age of patients was 59+/-8 years, there were 21 patients with unstable angina, and 21 with recent myocardial infarction (MI).

SURGICAL TECHNIQUE

Diseased LAD is bypassed with the internal thoracic artery graft (ITA). The anastomosis is made downstream from the significant proximal lesion of the LAD. A long arteriotomy (from 2 to 12 cm) is performed along the LAD up to the healthy arterial wall, followed by coverage with the onlay graft of ITA in such a fashion as to exclude the plaques from the LAD lumen. The wall of the new reconstructed LAD consisted of 75% of ITA and 25% of native LAD. The remaining part of the native LAD forms a posterior gutter giving the origins of septal and diagonal branches.

RESULTS

aortic cross-clamping time was 116 min, operative mortality rate was 3.2% (three patients), peri-operative infarction rate 6.6% (six patients). The follow-up was 29 months (SD=10). Of the 91 survivors, two were lost for follow-up and one died of non-cardiac causes. Of the 88 patients clinically evaluated, 81 were free from angina and other cardiac events, two had new myocardial infarction in a non-grafted area, two were in congestive heart failure, and three in angina class II. Sixty patients underwent angiography. There were 57 perfect-patency CAR (95%), two ITA string sign (competitive flow), two ITA occlusions (2.5%) and no re-stenosis.

CONCLUSIONS

CAR allows revascularisation of diffusely diseased LAD with acceptable operative mortality and morbidity, 2 years' good clinical results and graft patency. In this series, exclusion of plaques prevented plaque complications.

[Failure of internal thoracic-coronary artery bypass graft. What are the reasons?]

The aim of this study was to identify the causes of failure of coronary bypass grafting with the internal thoracic artery. A total of 512 internal thoracic artery grafts in 302 patients were reviewed. Control coronary angiography was performed after an average of 17.3 months (sigma = 4.1 months). Were considered as failures: 11 (2%) occluded grafts and 19 (4%) non-functional (narrowed internal thoracic artery) grafts. The appearances of the anastomosis, presence or absence of stenosis, origin of flow at the anastomosis and distal run-off of the grafted coronary artery, were analysed. Of the 19 non-functional grafts, there were no stenosis of the anastomosis of the narrowed internal thoracic arteries; in 14 cases, competitive flow was observed (2 internal thoracic artery steal syndromes by non-obstructed proximal collateral branches, 8 initially overestimated coronary stenoses, 4 secondary regressions of coronary stenosis); there was poor distal run-off of the grafted artery in 4 cases and significant coronary stenosis distal to the graft in one case. This study shows that, of the 30 failures of internal thoracic artery grafting, at least 2/3 were "avoidable" by a more accurate evaluation of the coronary stenosis on the preoperative coronary angiography and by better surgical technique.

[Failure of coronary artery bypass with the internal thoracic artery. Does extended use of the internal thoracic artery affect the patency of the coronary artery?]

OBJECTIVE

The aim of this study was to precise the circumstances of the failure of coronary artery bypass graft by internal thoracic artery (ITA).

METHODS

It was a retrospective study which compared angiographic results between several techniques of ITA graft; 512 coronary artery bypass graft have been realized on 302 patients: 115 single left ITA grafts, 78 sequential left ITA grafts, 48 bilateral pedicled ITA grafts, 61 bilateral ITA Y grafts. The mean interval between operation and reangiography was 17.3 months (s = 4.1 months). Graft failures were occluded and non functioning ITA grafts (threadlike ITA).

RESULTS

There were 11 occluded grafts (2%) and 19 non functionning grafts (4%). There was no difference of failure rate between the 4 techniques of ITA grafts (p > 0.05). The failure rate for right ITA grafts 13% was higher than for the left ITA grafts 4% (p < 0.001). The failure rate for obtuse marginal branch grafts 13% was higher than for left anterior descending artery grafts 3% (p < 0.001).

CONCLUSION

The extended use of ITA doesn't increase the risk of graft failure rate. The patency of obtuse marginal branch ITA graft is less than the patency of left anterior descending artery or diagonal branch ITA grafts.

Retrograde cold blood cardioplegia. Obliteration of the posterior interventricular vein in the coronary sinus improves cooling of the left ventricle posterior wall

The study hypothesis was that obliteration of the posterior interventricular vein in the coronary sinus avoids the back leak of cardioplegia to the right atrium and forces cardioplegia towards the posterior wall of the left ventricle and interventricular septum. A new retrograde cardioplegia cannula with a long balloon (3 cm) was designed which obstructs the posterior interventricular vein in the coronary sinus. The hypothesis was tested by a prospective randomized study in 52 consecutive patients who underwent coronary or aortic valve surgery. In group I (n = 26), the cannula prototype was used, while a standard cannula (balloon length 8 mm) was used in group II (n = 26). The cardioplegic solution was cold blood (14 degrees C). The posterior wall temperature was recorded when the anterior wall temperature reached 15 degrees C. In group I, 91% of patients had the same temperature in the anterior and posterior walls of the left ventricle versus 19% in group II (P < 0.05). The mean of the difference of left ventricular temperatures between anterior and posterior walls was 0.5 degrees C (sigma = 1.7) in group I versus 8 degrees C (sigma= 4.1 ) in group II (alpha < 0.05). In group I, 9.5% of patients had a posterior wall temperature > 20 degrees C versus 81% in group II (P < 0.05). Cooling of the posterior wall of the left ventricle is better in group I than in group II. As cooling and cardioplegia flow are closely linked, obliteration of the posterior interventricular vein in the coronary sinus improves left ventricular distribution of the cardiplegia.

Postinfarction atrioventricular septal rupture

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

[Left ventricular distribution of retrograde cardioplegia. Should the interventricular posterior vein be occluded in the coronary sinus?]

Retrograde cardioplegia is still controversial due to the heterogeneous left ventricular flow distribution particularly in the posterior wall. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two types of cannula. Fifty two patients were prospectively randomized to receive cold blood retrograde cardioplegia with manual inflating long balloon prototype cannula (group I, 26 patients) or with manual inflating short balloon cannula (group II, 26 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 15 degrees C. In group I, 91% of the patients had identical cooling in the anterior and posterior wall of the left ventricle, versus 19% in group II (p < 0.05). The mean temperature difference between anterior and posterior wall was 0.5 degrees C (standard deviation = 1.7) in group I versus 8 degrees C (standard deviation = 4.1) in group II (alpha < 0.05). The cannula with the long balloon allows a better left ventricular distribution of the cardioplegia flow than the short one because it occludes the interventricularis posterior vein in the coronary sinus.

[Angioplasty and coronary restoration using the internal mammary artery]

A technique of coronary surgical angioplasty is described. At the level of the stenosis the arteriotomy of the coronary artery is closed with the internal thoracic artery giving an enlargement patch effect. The major surface of the atherome plaque is excluded from the lumen of the anastomosis and put outside the suture line. The origins of the collateral arteries are kept in the vascular lumel. So the new remodeled coronary artery is formed with a small gutter of native coronary artery and the whole surface of the internal thoracic artery wall. In some cases it is useful to associate a limited endarterectomy to the angioplasty. Sixty-six surgical angioplasties have been done in extensive coronary disease. Operative mortality was 5.4% and myocardial infarction 5.4%.

Reimplantation of the right internal thoracic artery as a free graft into the left in situ internal thoracic artery (Y procedure). One-year angiographic results

Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% (n = 60), occlusion rate 1.6% (n = 1), and incidence of threadlike arteries 4.9% (n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% (n = 57), occlusion rate 6.5% (n = 4), and the incidence of threadlike arteries 8% (n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% (n = 58) and the occlusion rate, 4% (n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% (n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% (n = 58) and the rate of occlusion, 4.9% (n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% (n = 4/5).(ABSTRACT TRUNCATED AT 400 WORDS)

[Hospital procedures and surgical management of patients with stab wounds to the heart]

Stab wounds of the heart are frequent: one case every two and a half months in our service. In our series of 9 cases, only three were alive at arrival to the emergency ward, but in all of these three, treatment was simple requiring only simple wound suture without extra-corporeal circulation. Based on our experience and the data in the literature, we propose cooperation between three teams for managing these patients: anaesthesists, echocardiographists and cardiothoracic surgeons. The patients are admitted directly to the cardiothoracic operating theatre where the echocardiographist and the surgery team take charge. The surgical procedure depends on the general situation and especially on whether or not the echocardiologist can confirm haemopericardium immediately. Every patient with possible wound to the heart or major vessels should be managed directly by the cardiothoracic surgery team before of formal diagnosis has been established.

[Patency of left border artery bypass after 1 year; comparison of three techniques]

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p < 0.05).

[Vascular complications of lumbar disk surgery. Report of two cases and review of the literature on 122 cases]

We report two cases of right lumbar common iliac arteriovenous injury after an operation on the L4-L5 disk. One case was an arteriovenous fistula disclosed 5 years after the operation and in the other case, a postoperative acute haemorrhage. A retrospective study is carried out in the literature aiming at establishing the frequency of vascular injury in lumbar disk surgery, their nosologic definition, and the provided treatment. One hundred and twenty two observations were taken into account. The frequency cannot be determined. 78 of these observations (63.9%) reported an arteriovenous fistula between two elements of the aortic-cava intersection, with acute revelation (6.4%), sub-acute (19%) or late as a right cardiac failure (64%). Thirty one cases of acute haemorrhages through isolated arterial wound (25.4%), 3 cases of arterial or venous thrombosis (2.5%) and 10 cases of false aneurysms (8.2%) were found. The treatment was always surgical, sometimes in high emergency. In the case of haemorrhage the death rate was 21% and in the event of fistula 1.3%. Morbidity was 11.5%, mostly due to a post-phlebitic syndrome. These results reduce the mildness reputation of lumbar disk surgery all the more as recording of the complications is under estimated and most of them are found far from the initial act.

[Ventricular decompression and neuropsychiatric disorders in coronary surgery]

The marked decrease in neuropsychiatric morbidity (NPM) following coronary artery bypass (CAB) over a period of four years led us to carry out a retrospective study in order to identify the cause. Two hundred fifty-eight consecutive CAB procedures were performed between 1983 and 1986. For 133 patients (group A), the CAB procedure was performed with left ventricular vent (LVV) and for 125 patients (group B) without LVV. In group A, 93 patients (group A1) had cardiopulmonary bypass (CPB) with a bubble oxygenator and 40 patients (group A2) had CPB with a membrane oxygenator. In group B, 30 patients (group B1) had CPB with a membrane oxygenator without filter in the arterial line and 95 patients (group B2) had CPB with a membrane oxygenator and filter in the arterial line. The reduction in NPM arose from the removal of the LVV, as the incidence of NMP was in group A 24.6% versus 12.3% in group B (p < 0.05). The substitution of the bubble oxygenator by a membrane oxygenator does not alter the incidence of NPM: 23.3% in group A1 versus 27.5% in group A2 (p > 0.05) nor did incorporation of a filter in the arterial line: 10% in group B1 versus 13.1% in group B2 (p > 0.05). Introduction of air in the left ventricle via an LVV catheter opening and coronary arteriotomy therefore causes gazeous microembolic events responsible for NPM following CAB.

[Hypertrophic arteriovenous fistula for hemodialysis. Reduction by means of a constrictive perivenous mesh]

Aneurysmal arteriovenous fistulae (AVF) for haemodialysis often need surgical closure. We present a technique which consists of inserting the AVF into a constrictive perivenous mesh tube, thereby bringing the caliber of the AVF down to its normal size and restoring the normal shape of the forearm. Nine patients underwent AVF constriction without postoperative events. All AVFs were patent at 4 months. This technique also has the advantage of saving veins which, of course, is worthwhile in patients under haemodialysis.

[Revascularization of coronary arteries. Reimplantation of the right internal mammary artery into the left in situ mammary artery]

The distal latero-circumflex arteries and the posterior descending artery are located so far from the mammary arteries that they cannot be revascularized by the conventional procedure. Reimplantation of the right internal mammary artery (RIMA) used as a free graft into the left internal mammary artery (LIMA) in situ doubles the length of the RIMA, thus enabling the distal coronary arteries (lower lateral or posterior interventricular arteries) to be bypassed. The Y-shaped reimplantation anastomosis technique is described, and the immediate results obtained in 25 patients are reported. Seven angiographic controls were performed after 6 months to 1 year, and 6 anastomoses were perfectly patent. One RIMA is occluded (major competitive flow).