Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Functional Assessment of Mitral Regurgitation by Transthoracic Echocardiography Using Standardized Imaging Planes

OBJECTIVES

We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications.

BACKGROUND

The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined.

METHODS

Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings.

RESULTS

Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001).

CONCLUSIONS

In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.

Different effects of mibefradil and amlodipine on coronary vessels and during beta-adrenergic stimulation in conscious dogs

Coronary effects of Ca -channel blockers mibefradil and amlodipine were compared in conscious dogs. Ten dogs were instrumented for measurement of aortic and left ventricular pressures, circumflex coronary blood flow velocity (CBFv), and coronary diameter (CD). A permanent catheter was implanted in the circumflex coronary artery. At doses having no systemic effects (7.5-150 micro g/kg), mibefradil and amlodipine increased CBFv and CD dose dependently. At the same dose, mibefradil increased less CBFv than amlodipine. However, for a similar increase in CBFv induced by amlodipine, mibefradil increased CD more. BAY K8644, an L-type Ca -channel agonist, prevented the CBFv and CD responses to amlodipine, but minimally affected the coronary responses to mibefradil. Intracoronary isoproterenol (6 ng/kg) increased LV dP/dt max, CBFv, and CD. Amlodipine markedly altered these responses, while mibefradil did not affect LV inotropic response and slightly altered CBFv response to isoproterenol. Thus, in conscious dogs, both mibefradil and amlodipine exert coronary vasodilation, with different patterns on coronary conductance and resistance vessels and during beta-adrenergic stimulation. These differences could be related to their actions on different Ca channels.

The freestyle stentless aortic bioprosthesis: more about the subcoronary technique

Two years after aortic valve replacement with a Freestyle stentless aortic xenograft using the partial scallop inclusion technique, late prosthetic valve endocarditis developed with abscess formation in the space between the porcine and native human aortic wall. The presence of such a periprosthetic dead space exposes the patient to increased postoperative pressure gradients and the risk of superinfection.

Cardiac troponin I release after open heart surgery: a marker of myocardial protection?

BACKGROUND

Unlike creatine kinase MB isoenzyme, cardiac troponin I (cTnI) is a highly specific marker of myocardial injury. Its release has recently been studied after coronary artery bypass grafting operation. However, its significance after open heart surgery (OHS) remains to be determined. This protein release could be a marker of myocardial protection. We sought to study cTnI release after OHS in patients with normal coronary arteries and to compare it with cTnI release in patients after coronary artery bypass graft (CABG) surgery.

METHODS

Eighty-five patients undergoing OHS and 86 patients undergoing CABG were enrolled in the study. CTnI concentrations were measured in serial venous blood samples drawn before surgery and immediately, 12 hours, 24 hours, 48 hours, and 5 days after aortic unclamping.

RESULTS

In the OHS group and in the CABG group without acute myocardial infarction (AMI), cTnI peaked at 12 hours postoperatively (6.35 +/- 6.5 and 5.38 +/- 8.55 ng/mL, respectively) and normalized on day 5 postoperatively (0.57 +/- 2 and 0.72 +/- 1.62 ng/mL, respectively). CTnI concentration did not differ significantly between the OHS group and the CABG group in the absence of AMI for any samples considered. In the CABG group, 2 patients had AMI. In the OHS group, cTnI levels at 12 hours postoperatively were found to correlate closely with CPB and aortic cross-clamping (ACC) times, contrary to the CABG group, which correlated only with occurrence of AMI. CTnI release was independent of age and ejection fraction in either group.

CONCLUSIONS

cTnI release in patients after OHS with normal coronary arteries has the same profile as cTnI release in patients after CABG in the absence of AMI. However, its peak at 12 hours postoperatively is only correlated to ACC and CPB times, which is contrary to cTnI release after CABG surgery. This observation suggests that cTnI could be a marker of myocardial ischemia after OHS.

Preliminary experience with Silzone-coated St. Jude medical valves in acute infective endocarditis

BACKGROUND AND AIM OF THE STUDY

The rate of recurrent postoperative endocarditis after valve replacement in early-stage acute infective endocarditis is extremely high. Metallic silver coating of the sewing ring may improve the short- and long-term outcome after valve implantation. This report details our experience with the St. Jude Medical Silzone prosthesis in early surgical treatment of acute infective endocarditis.

METHODS

Ten patients (mean age 66.4 years) referred for native valve or prosthetic valve endocarditis were operated on between April 1998 and June 1999. The microorganisms responsible for the acute infection were Staphylococcus (n = 1), Streptococcus (n = 1) and Pseudomonas aeruginosa (n = 1); blood cultures remained negative in two cases. The indication for surgical treatment was related to hemodynamic condition (n = 5), a major cerebral event (stroke; n = 1), annulus abscess (n = 1), and echocardiographic evidence of large cuspal vegetations (n = 3). All patients had received preoperative intravenous antibiotics (mean 7.8 days). Four mitral, five aortic valve replacements, and one double mitral-aortic valve replacement, were performed after extensive debridement of the infected and necrotic tissues. Mean duration of postoperative antibiotic treatment was 32.3 days. Postoperative follow up (mean 6 months; range: 2-14.2 months) was 100% complete, and included prospective repeated transthoracic echocardiography at one week, and one, six and 12 months postoperatively.

RESULTS

One patient died early in the immediate postoperative period from pneumonia and major hypoxemia. All other patients are symptom-free, without evidence of recurrent infection and perivalvular leak.

CONCLUSION

Although these early results with the St. Jude Medical Silzone prosthesis require confirmation by more extensive studies, they infer that silver coating of the sewing ring may dramatically improve management of patients with active endocarditis.

Pseudointima in inflow conduits of left ventricular assist devices

BACKGROUND

Explant analysis of left ventricular assist systems (LVAS) should permit a better evaluation of long-term evolution of materials and tissue healing in patients supported by mechanical devices and a precise understanding of embolic phenomena, observed clinically.

METHODS

Five Novacor LVAS and their conduits have been explanted after 156 days (range 61-226 days) of mechanical support. The pseudo-intima (PI) developed in the inflow and outflow conduits was characterized microscopically, using monoclonal antibodies.

RESULTS

The morphological aspects of PI were quite different in the inflow and outflow conduits. Blood coagulation between the basal surface of the PI and the Dacron tube, irregular collagen type I matrix with plasma infiltration, macrophages, and neutrophil granulocyte elastase characterized the nonadherent, loose, and potentially thrombogenic PI growth in the inflow conduit. The PI from collagen types I and IV with circumferentially oriented alpha-smooth muscle cell actin-positive cells was anchored to the outflow conduits.

CONCLUSIONS

The observations, which have to be confirmed by a more extensive study on a larger number of specimens, suggest the role of the biomaterial itself, as well as the configuration, physical characteristics, and rheology in the conduit. They also suggest that thromboembolic complications of LVAS may eventually be related to this host tissue response.

Lack of durability of the Mitroflow valve does not affect survival

BACKGROUND AND AIM OF THE STUDY

The aim of the study was to compare the durability and risk of reoperation in patients undergoing isolated aortic valve replacement with either a porcine standard Carpentier Edwards or a Mitroflow pericardial valve.

METHODS

Follow up evaluation was performed in 118 patients receiving a Mitroflow valve (M) and 94 patients receiving a standard Carpentier Edwards porcine valve (CE) between 1980 and 1987. The two groups were identical in terms of clinical characteristics; only prosthesis size differed, with small-sized valves used more frequently among the Mitroflow group.

RESULTS

The risk of structural valve deterioration (SVD) was 2.3% per patient-year (pt-yr) in CE valves, and 5.4 per pt-yr in M valves. Freedom from SVD was 100%, 87 +/- 4% and 63 +/- 8% at 5, 10 and 15 years for CE valves, and 96 +/- 2%, 56 +/- 7% and 5 +/- 4% for M valves. Freedom of reoperation was 98 +/- 1%, 83 +/- 5% and 76 +/- 7% at 5, 10 and 15 years respectively for CE valves, and 94 +/- 2%, 55 +/- 7% and 11 +/- 9% for M valves. Despite the high number of valve-related reoperations, survival at 5, 10 and 15 years was not affected in M valve patients. Multivariate analysis (Cox model) showed that age and valve type were the two main risk factors for SVD and reoperation, though the latter factor had no impact on survival.

CONCLUSIONS

In younger patients (aged < 75 years), the CE valves offer superior results to the M counterpart in valve replacement. However, in patients aged > 75 years, pericardial and porcine bioprostheses demonstrate equivalent durability, despite post-implantation tissue changes in the former material.

Surgical treatment of subaortic stenosis: a seventeen-year experience

OBJECTIVE

The aim of the study was to analyze the long-term results of subaortic stenosis relief and the risk factors associated with recurrence and reoperation.

METHODS

One hundred sixty patients with subaortic stenosis underwent biventricular repair. Before the operation the mean left ventricle-aorta gradient was 80 +/- 35 mm Hg, 57 patients had aortic regurgitation, and 34 were in New York Heart Association functional class III or IV. Median age at repair was 10 years. For discrete subaortic stenosis (n = 120), 39 patients underwent isolated membranectomy, 67 underwent membranectomy with associated septal myotomy, and 14 underwent septal myectomy. Tunnel subaortic stenosis (n = 34) was treated by myotomy in 10 cases, myectomy in 12, septoplasty in 7, Konno procedure in 3, and apical conduit in 2. Aortic valve replacement was performed in 6 cases, mitral valve replacement in 2 cases, and mitral valvuloplasty in 4 cases.

RESULTS

There were 5 early (3.1%) and 4 late (4.4%) deaths. Within 3.6 +/- 3.3 years a recurrent gradient greater than 30 mm Hg was found in 42 patients (27%), 20 of whom had 26 reoperations. According to multivariable Cox regression analysis survival was influenced by hypoplastic aortic anulus (P =.01) and mitral stenosis (P =.048); recurrence and reoperation were influenced by coarctation and immediate postoperative left ventricular outflow tract gradients. At a median follow-up of 13.3 years, mean left ventricle-aorta gradient was 20 +/- 13 mm Hg. Relief of the subaortic stenosis improved the degree of aortic regurgitation in 86% of patients with preoperative aortic regurgitation. Actuarial survival and freedom from reoperation rates at 15 years were 94% +/- 1.3% and 85% +/- 6%, respectively.

CONCLUSION

Although surgical treatment provides good results, recurrence and reoperation are significantly influenced by previous coarctation repair and by the quality of initial relief of subaortic stenosis.

Preserved vasodilator effect of bradykinin in dogs with heart failure

BACKGROUND

In heart failure (HF), vasoconstrictor systems are activated and endothelium-derived vasodilation is blunted. Bradykinin, a potent vasodilator, may play an important role in this setting. However, it is not known whether its vasodilator effect is modified in HF.

METHODS AND RESULTS

Fourteen chronically instrumented dogs were studied in the control state and in pacing-induced HF (250 bpm for 3 weeks). The dose-dependent decrease in mean aortic pressure (MAP) induced by acetylcholine was significantly blunted in HF. In contrast, in both control and HF, bradykinin infusion caused similar dose-dependent decreases in MAP and increases in cardiac output (CO). This vasodilator effect of exogenous bradykinin was potentiated similarly in both states by enalaprilat, which blocks both angiotensin conversion and bradykinin degradation. For evaluating the role of endogenous bradykinin, the effects of enalaprilat were compared with those of ciprokiren, a pure renin inhibitor. In control, ciprokiren did not produce any effect. Enalaprilat, however, produced a significant decrease in MAP and a significant increase in CO, which were attributed to the inhibition of bradykinin degradation, because these effects were absent after pretreatment with Hoe 140 (a bradykinin B2 receptor antagonist). In contrast, in HF, vasodilator effects of ciprokiren were observed, but enalaprilat produced larger changes in MAP and CO, and after Hoe 140, the hemodynamic effects of enalaprilat were significantly decreased, showing the effects of endogenous bradykinin, which were similar to those measured in control.

CONCLUSIONS

In this model of HF with a blunted endothelium-derived vasodilation, the vasodilator effects of exogenous and endogenous bradykinin are preserved. These results suggest that bradykinin may play an important role in HF, in which vasoconstriction is present and endothelium-dependent vasodilation is blunted.

Pelvic leiomyoma in the right atrium

Intravenous leiomyomatosis is a condition characterized by intravenous growth of histologically benign smooth muscle tumor, originating in the uterus. A case of intravenous leiomyomatosis with right atrial extension in a 64-year-old woman is described. The atrial tumor was successfully removed with a single-stage approach via sternolaparotomy and total circulatory arrest using cardiopulmonary bypass.

Jarvik 2000 heart: potential for bridge to myocyte recovery

BACKGROUND

Mechanical bridge to left ventricular recovery is an emerging strategy for the treatment of heart failure. We sought to validate the use of a new intracardiac axial flow impeller pump for this purpose.

METHODS AND RESULTS

The Jarvik 2000 Heart was implanted into 30 sheep to ascertain mechanical reliability, biocompatibility, and hemodynamic function. We attempted but failed to anticoagulate with warfarin. Elective explants with survival were performed in 3 animals to simulate bridge to recovery. Extensive autopsy studies were performed in all other animals. At speeds between 8000 and 12 000 rpm the device pumped up to 8 L/min, captured all mitral flow, and augmented cardiac output with elevation of mean arterial pressure. The pump was silent and hemolysis negligible. Nonpulsatile flow did not adversely affect neurological or renal function. Device removal proved straightforward and safe. A fractured inflow bearing occurred in 1 early model. There were no other pump failures, but power interruption occurred when the sheep chewed the cables or head-butted the percutaneous pedestal. At autopsy, there was no thromboembolism or primary thrombus formation in any device. Pump occlusion occurred in 2 sheep with bacterial endocarditis. One electively explanted pump, previously switched off for 5 months, had no thrombus in the device or vascular graft.

CONCLUSIONS

The Jarvik 2000 Heart is a major advance in blood-pump technology and increases the scope of mechanical circulatory support. Reliability and ease of removal favor its use for bridge to myocyte recovery, as well as for bridge to transplantation or long-term support.

[Effects of high sodium intake on ventricular remodeling in mice]

BACKGROUND

Despite extensive research, controversy still exists regarding the role of dietary sodium intake on hypertension and left ventricular (LV) hypertrophy. Echocardiography is a powerful tool to assess LV hypertrophy and recent technical developments allow now its use in small animals.

METHODS

We examined the effect of high sodium intake on LV geometry using echocardiography in mice. Three groups of Swiss mice were submitted, for 8 weeks, to different salt diets (0.6, 2 and 4% NaCl; n = 12, n = 8 and n = 12 respectively). LV end-diastolic (ED) septal and posterior wall thicknesses, LV ED diameter were measured at baseline, 4 and 8 weeks.

RESULTS

At baseline, heart rate, LV ED septal and posterior wall thicknesses and LV ED diameter were similar between groups. At 8 weeks, for similar heart rate, LV ED posterior wall thickness were not different (0.6%: 0.64 +/- 0.01, 2%: 0.62 +/- 0.08 and 4%: 0.67 +/- 0.03 mm respectively) but LV septal wall thickness ass increased in a salt diet dependent manner (0.6%: 0.63 +/- 0.01, 2%: 0.75 +/- 0.01, 4%: 0.80 +/- 0.02 mm, p < 0.01). This increase was correlated with urinary sodium excretion (r = 0.84, p < 0.01) but occurred in the absence of change in arterial pressure (tail-cuff plethysmography; 0.6%: 135 +/- 6.2%: 127 +/- 4 and 4%: 139 +/- 9 mmHg respectively). The in-vivo interventricular septal remodeling was confirmed in perfused fixed preparations of hearts.

CONCLUSION

Echocardiography allows precise measurements of regional LV wall dimensions in mice, and high sodium intake, in the absence of hypertension, induces interventricular septal remodeling.

Stentless xenograft repair of the dissected aortic root

We used a Freestyle (Medtronic, Minneapolis, MN) porcine root to replace a regurgitant aortic valve and repair acute type A dissection. A Hemashield (Meadox Medicals, Oakland, NJ) graft was used to replace the ascending aorta with the "open anastomosis" technique. This method is a valuable alternative to conventional root replacement in acute type A dissection.

Reconstructive surgery in congenital mitral valve insufficiency (Carpentier's techniques): long-term results

BACKGROUND

Previous publications have stressed the benefits of mitral valve repair over mitral valve replacement in children. However, few communications have reported the long-term results and none with a follow-up of more than 10 years. This article reports our results in a series of 145 patients operated on for congenital mitral valve insufficiency by means of the same technique (Carpentier's technique) in a single center.

METHODS

Between 1970 and 1995, 145 patients younger than 12 years old underwent surgery for congenital mitral valve insufficiency. Mean age was 5.7 +/- 3.1 years, ranging from 0.17 to 12 years. Mitral valve insufficiency associated with atrioventricular defect, atrioventricular discordance, straddling mitral valve, acquired diseases, Marfan syndrome, and degenerative disease was excluded from this study. According to Carpentier classification, 31 patients had type I mitral valve disease (normal leaflet motion), 79 patients type II (leaflet prolapse), and 35 type III (restricted leaflet motion), with 15 having normal papillary muscles and 20 abnormal papillary muscles. Associated lesions were present in 51 patients (35%). A conservative operation was possible in 138 patients (95%). Among them, 70 patients required a prosthetic annuloplasty and 21 patients valve extension with a pericardial patch. Valve replacement was necessary in seven patients (5%).

RESULTS

In-hospital mortality was 5% (95% CL: 2.5% to 9.9%) (seven patients). No early death was observed in the group of patients who underwent valvular replacement. In-hospital mortality was as follows: type I, 9.6%; type II, 2.5%; and type III, 13%. No statistically significant difference was noted among patients with the different types of disease. Mean follow-up was 9.3 +/- 6.9 years (1 to 26 years), and cumulative follow-up was 1142 patient-years. Ten late deaths occurred. Actuarial survival at 10 years was 88% in patients who underwent valve repair and 51% in patients who underwent valve replacement. Late reoperation was required in 15% (n = 21) of patients who had undergone valve repair and 28% (n = 2) in patients with valve replacement. Causes of reoperation were recurrent left ventricular failure (n = 1), residual or recurrent mitral valve insufficiency (n = 17), mitral valve stenosis (n = 3), and calcification of the bioprosthesis (n = 2). No failure resulting from leaflet extension was observed. In the repair group, actuarial freedom from reoperation was 68% (95% CL: 80.5% to 51.5%) at 15 years, and the linearized rate of exposure to reoperation was 1.9% per patient-year. No thromboembolic event was observed in any group.

CONCLUSION

Congenital mitral valve insufficiency can be repaired in infancy with a low mortality. Conservative surgery with Carpentier's techniques is feasible in the majority of cases of congenital mitral valve insufficiency. This technique offers stable long-term results with a low rate of reoperation. Leaflet extension associated with prosthetic ring annuloplasty could prevent reoperations in selected cases.

Regional myocardial effects of intracoronary bradykinin in conscious dogs

This study examined in conscious dogs, the coronary and regional myocardial effects of bradykinin (BK) administered by intracoronary route and their modulation by an angiotensin-converting enzyme inhibitor. Eleven dogs were chronically instrumented with a left ventricular (LV) micromanometer, a circumflex coronary catheter, a flow probe, and ultrasonic crystals in the LV posterior wall. In the absence of systemic hemodynamic changes, BK (0.1-10 ng/kg i.c.) produced dose-dependent increases in coronary blood flow velocity (CBFV) and in LV posterior end-diastolic wall thickness (EDWT) but produced no change in LV regional myocardial function as assessed by LV posterior systolic wall thickening. The increases in LV EDWT and CBFV were linearly correlated. The BK B2 antagonist (HOE 140) abolished the effects of BK. Intracoronary enalaprilat (0.75 mg) extended the duration of the effect of BK on CBFV without modification of peak responses and induced a further increase in LV posterior EDWT but no change in LV regional myocardial function. Thus, in conscious dogs, the vasodilator effect of intracoronary BK alone or modulated by enalaprilat is not associated with changes in LV regional myocardial function.

[Operative risk in thoracic surgery]

Operative risk is encountered daily in thoracic surgery. Preoperatively, the risk can be evaluated by the pneumologist as well as the intensive care-surgery team. The parenchymal function and the patients respiratory capacity during the post-operative period should be evaluated. It is fundamental to evaluate heart function and vascular capacity. We discuss operative risk of dissection. The risk of bronchial fistulization is estimated at 5% (pneumonectomy) and 1% (lobectomy). Immediate complications include air leaks, rhythm disorders and post-operative bleeding. Thoracic drainage is a determining factor in thoracic surgery. The main problem remains post-operative respiratory failure especially since carcinological exeresis is usually carried out in patients with bronchopathies.

Anastomotic pitfalls in lung transplantation

Although airway, arterial, and venous connections required for lung transplantation appear simple, in practice we have encountered morbid early stenosis and obstructions, which are now avoided by technical modifications gradually made since 1985 in 134 cases (60 single lung and 74 double lung). Our initial eight double lung transplant procedures were done with tracheal anastomoses and omental wraps, but ischemic disruption, with a 75% (6 of 8) rate of complications, resulted in the subsequent use of bi-bronchial connections. A total of 192 bronchial anastomoses were reviewed (60 single lung, 66 double lung). Although all anastomoses were constructed between the donor trimmed to one to two rings above the upper lobe origin and the host divided at its emergence from the mediastinum, the suture technique has evolved. Nine (32%) of 28 cases with early bronchial anastomoses with end-to-end suture and intercostal muscle wrap had ischemic or stenotic complications, but the telescoping technique without wrap in 164 bronchial anastomoses reduced the problem to 12% (19 of 164). Twelve anastomoses required temporary intraluminal stenting. Vascular anastomotic obstructions occurred in five arterial (excessive length 2, short allograft artery 1, restrictive suture or clot 2) and two venous (excessive length 1, restrictive suture or clot 1) connections. Suspicion of arterial obstruction was prompted by persisting pulmonary hypertension and reduced flow to the allograft measured by postoperative nuclear scan and hypoxia. Venous obstructions were suggested by persisting radiographic and clinical pulmonary edema. Modifications of earlier techniques have improved our early success in lung transplantation and might be considered by others entering this demanding field.

[Coronary reoperations: indications and results]

The aim of this study was to assess the results of coronary reoperations and to determine the indications. Between January 1972 and December 1990, 166 coronary reoperations were performed in 161 patients (5 patients were operated three times). The interval between the first and second operation was 93 +/- 46 months. The interval between recurrence of symptoms and reoperation was 27 +/- 40 months. Recurrence of symptoms was related to isolated problems with the bypass grafts in 23% of cases, to an aggravation of the coronary disease without problems with the bypass grafts in 17% of cases and to an association of the two conditions in 60% of cases. Mortality in the first 30 postoperative days was 7.8% (13/161). The predictive factors of mortality were age over 70 years and an interval between recurrence of symptoms and reoperation of over 12 months. The causes of death were myocardial infarction (n = 5), left ventricular failure (n = 4), sudden death (n = 3), and arrhythmias (n = 1). The average follow-up period of survivors (n = 134) was 40 +/- 32 months. Four patients have been transplanted. Seven patients died secondarily. The cause of death was cardiac in 4 cases and non-cardiac in 3 cases. The actuarial 5 year and 10 year survival rates were 85 +/- 3%. Actuarial absence of myocardial infarction, angina, Class III-IV cardiac failure and transplantation was 87 +/- 4% at 5 years and 69 +/- 10% at 10 years. These figures show that coronary reoperation gives good functional results and long-term survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacological bridge to cardiac transplantation: current limitations

Addition of intravenous enoximone to sympathomimetic agents permits a rapid and drastic improvement in the clinical and hemodynamical condition of patients in cardiogenic shock referred for a mechanical bridge to transplantation. The present experience, based on the management of 52 patients, permits us to point out the current limitations of this pharmacological bridge: the rate of sudden death, the incompleteness of the physical rehabilitation of the patients, and the vanishing effect of intravenous enoximone.