Istaroxime treatment ameliorates calcium dysregulation in a zebrafish model of phospholamban R14del cardiomyopathy

The heterozygous Phospholamban p.Arg14del mutation is found in patients with dilated or arrhythmogenic cardiomyopathy. This mutation triggers cardiac contractile dysfunction and arrhythmogenesis by affecting intracellular Ca2+ dynamics. Little is known about the physiological processes preceding induced cardiomyopathy, which is characterized by sub-epicardial accumulation of fibrofatty tissue, and a specific drug treatment is currently lacking. Here, we address these issues using a knock-in Phospholamban p.Arg14del zebrafish model. Hearts from adult zebrafish with this mutation display age-related remodeling with sub-epicardial inflammation and fibrosis. Echocardiography reveals contractile variations before overt structural changes occur, which correlates at the cellular level with action potential duration alternans. These functional alterations are preceded by diminished Ca2+ transient amplitudes in embryonic hearts as well as an increase in diastolic Ca2+ level, slower Ca2+ transient decay and longer Ca2+ transients in cells of adult hearts. We find that istaroxime treatment ameliorates the in vivo Ca2+ dysregulation, rescues the cellular action potential duration alternans, while it improves cardiac relaxation. Thus, we present insight into the pathophysiology of Phospholamban p.Arg14del cardiomyopathy.

Chemical interactions between Saturn’s atmosphere and its rings

The Pioneer and Voyager spacecraft made close-up measurements of Saturn’s ionosphere and upper atmosphere in the 1970s and 1980s that suggested a chemical interaction between the rings and atmosphere. Exploring this interaction provides information on ring composition and the influence on Saturn’s atmosphere from infalling material. The Cassini Ion Neutral Mass Spectrometer sampled in situ the region between the D ring and Saturn during the spacecraft’s Grand Finale phase. We used these measurements to characterize the atmospheric structure and material influx from the rings. The atmospheric He/H2 ratio is 10 to 16%. Volatile compounds from the rings (methane; carbon monoxide and/or molecular nitrogen), as well as larger organic-bearing grains, are flowing inward at a rate of 4800 to 45,000 kilograms per second.

A surgical predictive risk model of in-hospital mortality for primary resectable lung cancer: Statistical analysis of 8,796 patients from a nationally representative database

7677

Background: The aim of this study was twofold: to identify factors associated with in-hospital mortality among patients operated on for primary resectable lung cancer and to construct a risk model that could be used prospectively to inform decisions and retrospectively to enable comparisons and outcomes. Methods: Data from a nationally representative thoracic surgery database were collected prospectively in 59 hospitals between June 1, 2002 and December 1, 2006. Only adult patients with more than 95% of completed data were selected for the final analysis (n = 8,796 patients). Logistic regression analysis was used to predict the risk of in-hospital mortality. A risk model was developed with a training set of data (50% of patients) and validated on an independent test set (50% of patients). Its fit was assessed by the Hosmer-Lemeshow test (larger p value signifies greater reliability), and predictive accuracy was indicated by the area under the receiver operating characteristic curve (c-index). Results: Of the 8,796 original patients, 255 (2.9%) died during the same hospital admission. Within the data used to develop the model, the factors found to be significantly associated with the occurrence of in-hospital mortality in a multivariate analysis were: age, gender, performance status (World Health Organization) classification, side, class of procedure (lobectomy or wedge resection versus pneumonectomy), tumor histology, TNM stages and presence of co-morbid disease. The model was reliable (Hosmer-Lemeshow test = 8.94; p = 0.35) and accurate: the c-index (95% confidence interval) = 0.83 (0.81 to 0.85) for the training set and 0.82 (0.79 to 0.85) for the test set of data. The correlation between the expected and observed number of deaths was 0.99. Conclusions: The validated multivariate model for risk of in-hospital mortality among adult patients requiring surgery for primary resectable lung cancer described in this report was developed with national data, uses only 8 variables and has good performance characteristics. It would be useful both for calculating the mortality risk of an individual patient and contrasting expected and observed mortality rates for an institution or independent clinician.

No significant financial relationships to disclose.

Blood warm reperfusion: a necessary adjunct to heart-valve surgery in low-risk patients?

AIM

The aim of this prospective, randomized study was to determine whether blood warm reperfusion improves myocardial protection provided by cold crystalloid cardioplegia in patients undergoing first-time elective heart-valve surgery, using cardiac troponin I release as the criterion for evaluating the adequacy of myocardial protection.

METHODS

Seventy patients with a left ventricular ejection fraction greater than 40% were randomly assigned to 1 of 2 myocardial protection strategies: 1) cold crystalloid cardioplegia with no reperfusion or 2) cold crystalloid cardioplegia followed by 2-minute blood warm reperfusion before aortic unclamping. Cardiac troponin I concentrations were measured in serial venous blood samples drawn immediately prior to cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 h.

RESULTS

Randomization produced 2 equivalent groups. The total amount of cardiac troponin I released (7.17+/- 14.8 mg in the crystalloid cardioplegia with no reperfusion group and 5.82+/-4.66 mg in the crystalloid cardioplegia followed by blood warm reperfusion group) was not different (P > 0.2). Cardiac troponin I concentration did not differ for any sample in either of the 2 groups. The total amount of cardiac troponin I released was higher in patients who required inotropic support (9.14 +/-16.2 mg) than those who did not (4.73+/-4.52 mg; P = 0.009).

CONCLUSIONS

Our study shows that adding blood warm reperfusion to cold crystalloid cardioplegia provides no additional myocardial protection in low-risk patients undergoing heart-valve surgery.

["Mammary loop" technique--new method of multiple coronary revascularization using internal mammary arteries]

The internal mammary arteries are "the gold standard" conduits for coronary by-pass because their' s patency is superior to the saphenous graft. There are some surgical techniques which allow to use the entire length of the mammary arteries: the Y graft, the T graft and the pi graft. We describe recently the "mammary loop" technique that allows to make a Y graft using only one internal mammary artery. This technique also simplifies the construction of a pi graft. In this article we present the variants of this technique and discuss the indications and our early experience results.

Endovascular treatment of the traumatic rupture of the aortic isthmus

The traumatic rupture of the aortic isthmus is a dehiscence of all or part of the aortic wall, occurring as a result of a closed thoracic trauma. Standard surgical technique requires left thoracotomy, aortic cross-clamping and use of the cardiopulmonary by-pass to prevent ischemic complications, in special the neurologic and visceral ones. The endovascular treatment of these lesions is a more simple solution and there are recent reports on the stent-grafting of the isthmic rupture of the thoracic aorta. We report three cases of successful endovascular repair of the aortic isthmic rupture and we discuss the emergency indications, the advantages and the limits of this technique.

[Myocardial microdialysis. Importance and potential in cardiovascular research]

The microdialysis expanded mainly in the field of the neuro- and the dermopharmacology with the study of the transmitters released in the central nervous system and derm. Since ten years, this tool gained other disciplines such as cardiology and cardiovascular surgery. Indeed, the collection and the study of the molecules released in the myocardic interstitial fluid without deteriorating it functioning made microdialysis a powerful tool in the study of the extracellular environment of the cardiomyocyte. The purpose of this study is to point out the principle of the microdialysis and to show its various uses in the field of cardiovascular pharmacology.

[Effects of nitric oxide on cardioprotection prior to ischemia-reperfusion]

This study aimed at evaluating the role of nitric oxide (NO) when generated 24 h prior to ischemia-reperfusion. Three groups were studied in an isolated buffer-perfused heart model: Control (saline = 3.3 mL/kg, n = 10), the precursor of NO, L-arginine, (500 mg/kg, n = 10) and an inhibitor of NO synthase, L-NAME, (10 mg/kg, n = 9). All groups were injected intraperitoneally 24 h before heart extraction. Nitrites, nitrates (an index of nitric oxide release) and cardiac troponine I were assayed. During the reperfusion period, there was a low release of nitric oxide and cardiac troponine I associated with improved recovery of post-ischemic myocardial function. These results indicate that in this model, the pre-treatment improved myocardial function and thus, NO could play a role as a trigger and not as a mediator of cardioprotection.

Effects of L-arginine administration before cardioplegic arrest on ischemia-reperfusion injury

BACKGROUND

Administration of L-arginine during reperfusion or its addition to cardioplegic solution has been shown to protect myocardium against ischemia-reperfusion injury. This study aimed at evaluating the role of L-arginine in ischemia-reperfusion injury when administered intraperitoneally 24 hours before cardioplegic arrest.

METHODS

Two groups of Sprague-Dawley rats (control, n = 10; and L-arginine, n = 10) were studied in an isolated buffer-perfused heart model. Both groups were injected intraperitoneally 24 hours before ischemia. Before experimentation blood samples were collected for cardiac troponin I and cGMP analysis. In the coronary effluents, cardiac troponin I, adenosine, cyclic guanosine monophosphate, and nitric oxide metabolites were assayed.

RESULTS

Before heart excision, serum cardiac troponin I concentrations were higher in the L-arginine than in the control group (0.037 +/- 0.01 versus 0.02 +/- 0.05 microg x L(-1); p < 0.05). During reperfusion, cardiac troponin I release was lower in the L-arginine than in the control group (0.04 +/- 0.01 versus 0.19 +/- 0.03 ng x min(-1); p < 0.05). The coronary flow as well as the left ventricular developed pressure were higher in the L-arginine than in the control group before ischemia and remained so throughout the experimentation.

CONCLUSIONS

These results indicate that L-arginine administered intraperitoneally 24 hours before cardioplegic arrest reduced myocardial cell injury and seems to protect myocardium against ischemia-reperfusion injury.

False lumen patency as a predictor of late outcome in aortic dissection

Aortic dissection (AD) is a disease with a high-risk of mortality. Late deaths are often related to complications in nonoperated aortic segments. Between 1984 and 1996, we retrospectively analyzed the data of 109 patients with acute AD (81 men and 28 women; average age 61 +/- 14 years). All imaging examinations were reviewed, and a magnetic resonance imaging examination was performed at the time of the study. Aortic diameters were measured on each aortic segment. Predictive factors of mortality were determined by Cox's proportional hazard model, in univariate and multivariate analyses, using BMDP statistical software. Follow-up was an average of 44 +/- 46 months (range 24 to 164). Actuarial survival rates were 52%, 46%, and 37% at 1, 5, and 10 years, respectively, for type A AD versus 76%, 72%, and 46% for type B AD. Predictors of late mortality were age >70 years and postoperative false lumen patency of the thoracic descending aorta (RR 3.4, 95% confidence intervals 1.20 to 9.8). Descending aorta diameter was larger when false lumen was patent (31 vs 44 mm; p = 0.02) in type A AD. Furthermore, patency was less frequent in operated type A AD when surgery had been extended to the aortic arch. Thus, patency of descending aorta false lumen is responsible for progressive aortic dilation. In type A AD, open distal repair makes it possible to check the aortic arch and replace it when necessary, decreases the false lumen patency rate, and improves late survival.

Myocardial fixation of anticardiac troponin I antibody and cardiac troponin I release

BACKGROUND

The threefold aim of this experimental study was to test the correlation of cardiac troponin I released to myocardial infarction size and myocardial fixation of anticardiac troponin I antibody and to determine how long after myocardial infarction the measure of cardiac troponin I concentration can evaluate myocardial infarction size.

METHODS

Forty rabbits were assigned either to a control group or to an experimental preconditioned group. Infarction was obtained by tightening a snare around the left anterior descending artery. Serial venous blood samples were drawn for measurement of cardiac troponin I. The rabbits were sacrificed at 72 hours and a histological study was performed to determine the infarct size and the size of the area void of fixation of anticardiac troponin I antibody.

RESULTS

There was a linear correlation between the total amount of CTn I released and both infarct size (r=0.45, p<0.02) and the size of the area void of anti-cardiac troponin I antibody (r=0.47, p<0.02). These two sizes were strongly correlated (r=0.95, p<0.02). The hour 9 CTn I sample was the best correlated with both the infarct size (r=0.47, p<0.02) and the size of area void of anticardiac troponin I antibody (r=0.45, p<0.02).

CONCLUSIONS

Our study shows that: 1) cardiac troponin I release is correlated to both myocardial infarction size and the size of area void of fixation of anticardiac troponin I antibody, 2) the area void of anticardiac troponin I antibody fixation includes the whole ischemic area, and 3) evaluation of myocardial infarction size can be obtained by CTn I concentration as early as the ninth hour.

Perceived health status in patients over 70 before and after open-heart operations

AIM

to evaluate improvement and predictors of improvement in patients' perceived health status after cardiac surgery in older patients.

METHODS

three hundred and seventy-seven patients from three different departments of cardiac surgery completed the Nottingham Health Profile questionnaire before and 1 and 2 years after open-heart surgery. We analysed pre- and postoperative data and pre- and postoperative Nottingham Health Profile scores.

RESULTS

the mean age was 74+/-3 years. The comparison between pre- and postoperative scores showed an improvement in all but the social isolation section. Logistic regression showed that the predictors of patients who became worse after surgery were (i) in the energy section: age over 75 [odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.02-3.2], coronary artery disease (OR = 2.4, 95% CI = 1.04-3.6) and postoperative events (OR = 1.9, 95% CI = 1.01-3.7); (ii) in the physical mobility section: diabetes mellitus (OR = 2.4, 95% CI = 1.2-4.7); and (iii) in the social isolation section: physical mobility impairment (OR = 3.4, 95% CI = 1.3-8.7).

CONCLUSIONS

cardiac surgery improves perceived health status in patients over 70. This improvement is better for those undergoing aortic valve replacement than for those undergoing coronary artery bypass surgery. Comparison with reference scores for a standard population shows that, even when successful, cardiac surgery results in fatigue and persistent sleep disturbance in older patients.

Preoperative quality of life as a predictive factor of 3-year survival after open heart operations

BACKGROUND

The aim of this prospective study was twofold: to determine the evolution of quality of life in heart surgery patients through the first 3 postoperative years using the Nottingham Health Profile questionnaire and to determine whether preoperative quality of life influences 3-year survival.

METHODS

From January to July 1994, 215 patients underwent elective open heart operation in our department. Patients filled in the Nottingham Health Profile questionnaire five times: preoperatively, postoperatively at month 3, and at each anniversary of their operation for 3 years. The evolution of quality of life scores through time were compared using analysis of covariance with repeated measures. Analysis of 3-year survival prognostic factors was achieved using the Cox proportional hazards model.

RESULTS

Quality of life scores varied through time, but not significantly. Multivariate analysis showed two independent risk factors to influence 3-year survival: dyspnea class (III-IV versus I-II, relative risk = 2.80, 95% confidence interval = 1.2 to 6.5) and the energy section of the Nottingham Health Profile questionnaire (relative risk = 1.02 by unit, 95% confidence interval = 1.01 to 1.03).

CONCLUSIONS

Our study shows quality of life scores to be stable for the first 3 years after operation and the preoperative energy score to be predictive of 3-year survival.

Intermediate lukewarm (20 degrees c) antegrade intermittent blood cardioplegia compared with cold and warm blood cardioplegia

BACKGROUND

In the field of intermittent antegrade blood cardioplegia, 3 levels of temperature are commonly used: (1) cold (8 degrees C); (2) tepid (29 degrees C); and (3) warm (37 degrees C). Given the 21 degrees C spread and the metabolic changes that can occur between cold (8 degrees C) and tepid (29 degrees C) cardioplegia, we thought it worthwhile to test a temperature halfway between the cold and tepid levels. The aim of this study was to test the quality of myocardial protection provided by intermediate lukewarm (20 degrees C) cardioplegia by comparing it with cold and warm cardioplegia. Protection was assessed by measuring cardiac troponin I release.

METHODS

One hundred thirty-five patients undergoing coronary artery bypass grafting were enrolled in a prospective randomized trial comparing cold (8 degrees C), intermediate lukewarm (20 degrees C), and warm (37 degrees C) antegrade intermittent blood cardioplegia. Cardiac troponin I concentrations were measured in serial venous blood samples.

RESULTS

The total amount of cardiac troponin I released was significantly higher in the cold group (4.7 +/- 2.3 microg) than in the intermediate lukewarm (3.4 +/- 2.0 microg) or the warm (3.1 +/- 2.7 microg) groups. The cardiac troponin I concentration was significantly higher at hour 6 in the intermediate lukewarm group (1. 23 +/- 0.55 microg/L) than in the warm group (0.89 +/- 0.50 microg/L).

CONCLUSIONS

Intermittent antegrade intermediate lukewarm blood cardioplegia is appropriate and clinically safe. Cardiac troponin I release suggests that intermediate lukewarm cardioplegia is better than cold cardioplegia but less effective than warm cardioplegia in low-risk patients. We therefore recommend the use of warm cardioplegia in low-risk patients.

Determination of cardiac troponin I forms in the blood of patients with acute myocardial infarction and patients receiving crystalloid or cold blood cardioplegia

To determine the forms of cardiac troponin I (cTnI) circulating in the bloodstream of patients with acute myocardial infarction (AMI) and patients receiving a cardioplegia during heart surgery, we developed three immunoenzymatic sandwich assays. The first assay involves the combination of two monoclonal antibodies (mAbs) specific for human cTnI. The second assay involves the combination of a mAb specific for troponin C (TnC) and an anti-cTnI mAb. The third assay was a combination of a mAb specific for human cardiac troponin T (cTnT) and an anti-cTnI mAb. Fifteen serum samples from patients with AMI, 10 serum samples from patients receiving crystalloid cardioplegia during heart surgery, and 10 serum samples from patients receiving cold blood cardioplegia during heart surgery were assayed by the three two-site immunoassays. We confirmed that cTnI circulates not only in free form but also complexed with the other troponin components (TnC and cTnT). We showed that the predominant form in blood is the cTnI-TnC binary complex (IC). Free cTnI, the cTnI-cTnT binary complex, and the cTnT-cTnI-TnC ternary complex were seldom present, and when present, were in small quantities compared with the binary complex IC. Similar results were obtained in both patient populations studied. These observations are essential for the development of new immunoassays with improved clinical sensitivity and for the selection of an appropriate cTnI primary calibrator.

Warm reperfusion and myocardial protection

BACKGROUND

The aim of this study was to determine whether warm reperfusion improves myocardial protection with cardiac troponin I as the criteria for evaluating the adequacy of myocardial protection.

METHODS

One hundred five patients undergoing first-time elective coronary bypass surgery were randomized to one of three cardioplegic strategies of either (1) cold crystalloid cardioplegia followed by warm reperfusion, (2) cold blood cardioplegia followed by warm reperfusion, or (3) cold blood cardioplegia with no reperfusion.

RESULTS

The total amount of cardiac troponin I released tended to be higher in the cold blood cardioplegia with no reperfusion group (3.9+/-5.7 microg) than in the cold blood cardioplegia followed by warm reperfusion group (2.8+/-2.7 microg) or the cold crystalloid cardioplegia followed by warm reperfusion group (2.8+/-2.2 microg), but not significantly so. Cardiac troponin I concentration did not differ for any sample in any of the three groups.

CONCLUSIONS

Our study showed that the addition of warm reperfusion to cold blood cardioplegia offers no advantage in a low-risk patient group.

Crystalloid versus cold blood cardioplegia and cardiac troponin I release

BACKGROUND

Cardiac troponin I (CTnI) has been shown to be a marker of myocardial injury. The aim of this study was to compare antegrade crystalloid cardioplegia with antegrade cold blood cardioplegia with warm reperfusion using CTnI release as the criteria for evaluating the adequacy of myocardial protection.

METHODS AND RESULTS

Seventy patients were randomly assigned to receive crystalloid or blood cardioplegia. CTnI concentrations were measured in serial venous blood samples drawn just before cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 hours and daily thereafter for 5 days. ANOVA with repeated measures was performed to test the effect of the type of cardioplegia on CTnI release. The total amount of CTnI released was higher in the crystalloid cardioplegia group than in the blood cardioplegia group (11.2 +/- 8.9 versus 7.8 +/- 8.6 micrograms, P < .02). CTnI concentration was significantly higher in the crystalloid group than in the blood group in the samples drawn at hours 9 and 12. Three patients in each group had ECG evidence of perioperative myocardial infarction. Eight patients in the crystalloid group and five patients in the blood group had CTnI evidence of perioperative myocardial infarction. CTnI release was significantly lower in patients requiring no electrical defibrillation after aortic unclamping.

CONCLUSIONS

Cold blood cardioplegia followed by warm reperfusion is beneficial in an unselected group of patients with a preserved left ventricular function undergoing an elective first coronary artery bypass grafting. CTnI allowed the diagnosis of small perioperative necrotic myocardial areas. The need for electrical defibrillation after aortic unclamping was related to a higher release of CTnI. A further study is necessary to determine whether this technique was beneficial because of cold blood cardioplegia, warm reperfusion, or both.

Crystalloid cardioplegia route of delivery and cardiac troponin I release

BACKGROUND

Cardiac troponin I (CTn I) has been shown to be a marker of myocardial injury. Incomplete distribution of cardioplegic solution may be responsible for injury in jeopardized myocardial areas. The aim of this study was to compare CTn I release with respect to the route of delivery of crystalloid cardioplegia, either antegrade only or initially antegrade followed by retrograde cardioplegia for the remainder of the operation, in patients undergoing elective coronary artery bypass grafting.

METHODS

Sixty patients were randomly assigned to one of two cardioplegia groups. Cardiac troponin I concentrations were measured in serial venous blood samples drawn just before cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 hours and daily thereafter for 5 days. Analysis of variance with repeated measures was performed to test the effect of route of delivery, coronary disease, collateral circulation, risk of cardioplegia maldistribution, and number of grafts on release of CTn I.

RESULTS

Compared with the antegrade route, the combined route offered no advantage in an unselected group of patients undergoing an elective first cardiac operation and having preserved left ventricular function. The CTn I concentration did not differ between groups for any of the samples considered. In patients with major left main coronary artery stenosis, CTn I release was significantly higher at hour 9 in the antegrade group than in the group with combined delivery.

CONCLUSIONS

A combined route of delivery of crystalloid cardioplegia is beneficial in patients with major stenosis of the left main coronary artery. Cardiac troponin I sensitivity is relevant in this study. Release of CTn I should be useful in determining the best form of myocardial protection for each patient.

Effects of myocardial ischemia on the release of cardiac troponin I in isolated rat hearts

BACKGROUND

The twofold aim of this experimental study was (1) to verify the correlation between the duration of ischemia and concentration of cardiac troponin I and (2) to compare the release of cardiac troponin I with histologic findings.

METHODS

Experiments were done on 18 rat hearts, which were perfused according to the Langendorff method, immediately after excision in group I (control group) and after immersion for 3 hours (group II) and 6 hours (group III) in St. Thomas' Hospital solution at 4 degrees C. During reperfusion, the release of cardiac troponin I, creatine kinase isoenzyme MB, and lactate dehydrogenase, the recovery of left ventricular pressure, and heart rates were compared among the three groups. After the experiment, three samples of myocardium (left ventricle, right ventricle, and septum) were taken for histologic examination.

RESULTS

Cardiac troponin I concentration was significantly higher in group III than in groups I and II and in group II compared with group I. Cardiac troponin I concentration increased as the ischemic period increased. The relation between cardiac troponin I release and ischemic duration tended to be linear. Creatine kinase MB and lactate dehydrogenase concentrations did not differ from one group to the other. Left ventricular pressure was not significantly different among the groups. In the control group, no heart had more than 10% of the myocytes affected. One of six hearts in group II and three of six in group III had more than 10% of myocytes affected.

CONCLUSION

This experimental study showed (1) that cardiac troponin I is an early marker of ischemic injury and (2) that cardiac troponin I concentration increases as the ischemic period increases. Early cardiac troponin I release appears to correlate with the extent of ischemic injury in rats undergoing buffer perfusion.

Is surgery for aortic stenosis justified in patients over 75 years of age?

The upper age limit for cardiac surgery has constantly been extended since the 1980's, with the most pronounced extension observed in surgery of the calcified aortic stenosis (CAS). The aim of this study was to examine whether surgery is beneficial to the elderly population in terms of hospital mortality, long-term survival and quality of life. Between January 1989 and October 1992, 95 patients over 75 years of age underwent aortic valvular replacement (AVR) for CAS. There were 54 male and 41 female patients with a mean age of 79.7 +/- 2.8 years. All of them suffered from isolated or predominant CAS, associated with a coronary lesion requiring additional bypass procedures in 14 cases. Before surgery 67% of the patients were in NYHA class III and IV and 30% of them had suffered from acute pulmonary edema. Surgical priority was urgent in 10 patients. Mean aortic clamp time was of 55 minutes for the isolated CAS and 78 minutes for the bypass-associated CAS. A Carpentier-Edwards supra-annular bioprosthesis was implanted in 95.7% of the cases, associated with coronary bypass in 14 cases, with a mean of 1.6 bypasses per patient. Global hospital mortality was 11.5%. Emergency surgery was a predictive factor of in hospital mortality in multivariate analysis. Among the 84 survivors, 12 died secondarily, 4 of them due to cardiac causes during the follow-up period (26 +/- 4 months); similar to the mortality rate of the global population for the same age. The factors responsible for this late mortality in multivariate analysis were poor left ventricular status and diabetes mellitus. Survivor's quality of life is excellent with 78.6% of patients termed class I, autonomous and free of sequelae.

IN CONCLUSION

despite an operative mortality rate much higher than in patients under 70, AVR for CAS is justified even in patients over 75 years as it offers a good quality of survival and a life expectancy identical to that of the general population of the same age.

Inter-observer reliability in the interpretation of coronary angiograms

The interpretation of coronary angiograms is indispensable in determining procedure in coronary surgery. The aim of this study was to measure the overall reliability of a group of surgeons in the interpretation of coronary angiograms, surgical procedure and the evaluation of operative risk. Ten coronary angiograms were interpreted by eight cardiac surgeons at four different medical centers. Evaluation of coding discrepancies, in this case of multiple raters applying an ordinal-scale classification scheme (0, 1, 2) with no expert yardstick available for coding, was explored by a two-way random factor analysis of variance. Reliability was substantial for the assessment of stenosis irrespective of the artery (intraclass correlation coefficient (ICC) ranging from 0.92 to 1), and good for the distal part of the artery (ICC ranging from 0.83 to 0.86) as well as for the collateral provision (ICC ranging from 0.75 to 0.94). Agreement between surgeons was good with respect to the number of bypasses to be performed (ICC = 0.88). The number of bypass per patient varied from 2.6 to 3.2 depending on the surgeon. Agreement as to whether or not to bypass was substantial for the right coronary artery (ICC = 0.92), good for the marginal artery (ICC = 0.87) and fair for the left anterior descending artery (ICC = 0.60) and the circumflex artery (ICC = 0.60). There was a higher rate of agreement concerning inferior wall motion (ICC = 0.98) than of the anterior wall motion (ICC = 0.78). Agreement was substantial for ejection fraction (ICC = 0.93), operative risk (ICC = 0.93) and the type of coronary tree (ICC = 0.85). With respect to the overall set of items, no one surgeon disagreed significantly with the rest of the group. Some disagreement regarding anatomy suitable for revascularization exists between surgeons. Surgical assessment of risk is similar. Cardiac surgeons quickly learn to assess risk in a similar manner, even though they might not always graft the same anatomic vessels or assess regional wall motion similarly.

Prospective study of quality of life before and after open heart operations

BACKGROUND

The aim of this prospective study, with completion of questionnaires before and 3 months after open heart operations, was to evaluate the improvement of quality of life brought about by these operations and the predictors of this improvement.

METHODS

The Nottingham health profile questionnaire contains 38 subjective statements divided into six sections: energy, physical mobility, emotional reaction, pain, sleep, and social isolation. Factors influencing quality of life scores were determined by analysis of covariance. Factors influencing the status of the patients (improved or worsened) were determined by logistic regression.

RESULTS

From January to July 1994, 215 consecutive patients underwent elective open heart operations. The comparison between mean preoperative and postoperative scores showed an improvement in all sections of quality of life. An average of 80% of patients were improved by their operations. Independent predictors of less improvement of quality of life scores were as follows: for the energy section, age over 70 and New York Heart Association functional class III or IV; for sleep, age over 70; for physical mobility, New York Heart Association functional class III or IV; for social isolation, female gender; and for pain, age over 70 and abnormal segmental wall motion. Independent predictors of patients worsened by operation were as follows: New York Heart Association functional class III or IV in the energy section (odds ratio = 3.7, 95% confidence interval 1.4 to 9.8) and in the physical mobility section (odds ratio = 2.4, 95% confidence interval 1.02 to 5.5), female gender in the social isolation section (odds ratio = 2.8, 95% confidence interval 1.03 to 7.7), and presence of at least one comorbid disease in the emotional reaction section (odds ratio = 2.5, 95% confidence interval 1.17 to 5.2).

CONCLUSIONS

Cardiac operations improve quality of life in patients. The improvement is similar for patients undergoing coronary artery bypass grafting versus valve replacement, and for patients with no postoperative events versus those with nonlethal postoperative complications. The strongest predictive factors for quality of life are age and New York Heart Association functional class.

Quality of life after open-heart surgery in patients over 75 years old

In a postal study we used the Nottingham Health Profile questionnaire to assess the quality of life of elderly survivors of open-heart surgery. From January 1984 to October 1993, 146 patients over 75 years of age underwent open-heart surgery in the Department of Cardiovascular Surgery at Beasançon (France). Eleven patients (7. 5%) died in the immediate post-operative course. Patients' mean follow-up was 3.4 +/- 2.4 years. Fourteen patients died during follow-up. One hundred and four completed Nottingham Health Profile questionnaires were returned. Five per cent of the patients lived in an old people's home. Six per cent of the patients were unable to walk at all. One patient out of five felt isolated. Fifteen per cent of the patients were in constant pain. Half of the patients took sleeping pills. Conversely, 87% of the patients felt an improvement after surgery. Sixty-two per cent continued to drive. Ninety-seven patients (92%) did at least one of the following three activities: watched television, listened to the radio, read books or magazines. Fifty-eight patients (56%) walked on a regular basis. The different types of pathology, of surgical procedures and whether or not a pacemaker was implanted during the post-operative course were not reflected in the quality of life (QOL) scores. After cardiac surgery, most of the patients were physically autonomous and related to their exterior world.

Myocardial revascularization using both attached internal thoracic arteries. Mid-term clinical evaluation of 117 cases

The current trend in myocardial revascularization is to use arterial grafts in most, if not all cases. The right internal thoracic artery was a logical choice once the left internal thoracic artery patency on the LAD was known. This study presents our experience of using both attached internal thoracic arteries (ITA). Between January and October 1990, 159 myocardial revascularizations were performed in our department. In 117 cases, bilateral ITA grafting was used with non exclusion criteria. There were 100 male and 17 female patients, with a mean age of 61 +/- 8. The LITA was anastomosed to the LAD in 44 cases, and to the marginal artery in 74. The RITA was anastomosed to the LAD in 68 cases, to the marginal artery in 47 and to the right coronary artery in 2. An average of 3.5 bypasses per patient, including saphenous vein grafts, were performed. Six patients (5%) died within 30 days. Four patients (3.4%) were diagnosed as having periperative myocardial infarcts. There were no reoperations for bleeding. One patient (0.9%) presented a sternal wound infection. Mean follow-up was 18 +/- 7 months. Six patients died during the follow-up and the survival rate was 91%. Ninety-five patients (91%) were symptom-free, 9 patients had a recurrent angina. Postoperative coronary angiography was performed in 11 patients (10%).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of cardiac troponin I as a marker of perioperative myocardial ischemia

Troponin I is a contractile protein comprising three isoforms, two related to the skeletal muscle and one to the cardiac fibers. Cardiac troponin I (CTn I) is specific, without any cross-reactivity with the other two. Several studies have demonstrated its release after acute myocardial infarction. In contrast, CTn I never has been found in a healthy population, marathon runners, people with skeletal disease, or patients undergoing non-cardiac operations. Thus, CTn I is a more specific marker of cardiac damage than common serum enzymes. It is also more sensitive, allowing diagnosis of perioperative microinfarction and detection of acute myocardial infarction much earlier after the onset of ischemia (4 hours). Using a rapid one-step assay, we measured the release of CTn I in two groups of patients after operation: 20 with calcified aortic stenosis and normal coronary arteries (aortic valve replacement group and control group) and 20 undergoing coronary artery bypass grafting. In the overall population CTn I peaked at hour 6 and practically disappeared after day 5. Mean values were higher in the coronary artery bypass grafting group. In the aortic valve replacement group, a positive correlation was found between aortic cross-clamping time and CTn I, which is a reliable marker of cardiac ischemia during heart operations and can be used to evaluate cardioprotective procedures.

Aortic valve replacement in the elderly: a comparative assay of potential risk factor modification

From January 1989 to October 1992, 208 consecutive patients underwent isolated aortic valve replacement for calcified aortic stenosis in our department. Since the mean age of this patient population was 70 +/- 9 years, a retrospective clinical study was completed to assess the potential influence of advanced age on the independent predictors of early and late mortality. Hospital mortality was 6.2% (13 patients). Total follow up was 422.5 patient-years with a mean of 26 months. Nineteen patients died during the follow up period, equivalent to 4.5% per patient-year late mortality rate. Survival including hospital death was 88 +/- 2%, 86 +/- 2% and 79 +/- 4% at one, two and three years respectively. Eighteen variables as potential predictors of early and late mortality were studied. Predictors of hospital mortality were determined by logistic regression analysis, and those of late mortality by Cox proportional hazard model. Results were expressed as odds ratio (OR) or relative risk (RR). Age greater than 70 years (OR = 9.8, 95% CI = 1.2 to 80) and emergency surgery (OR = 8, 95% CI = 2.1 to 31) appeared as independent predictors of hospital mortality in multivariate analysis. Age above 75 years (RR = 3, 95% CI = 1.1 to 8.3), preoperative acute pulmonary edema (RR = 2.9, 95% CI = 1.1 to 7.7) and emergency surgery (RR = 4.2, 95% CI = 1.2 to 15) were independently associated with decreased late survival. Advanced functional class (NYHA III-IV) was shown to be an independent predictor of early or late mortality only in univariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

A non-resective therapy for abdominal aortic aneurysm: intravascular thrombosis by dropping inflatable balloons

A case of subrenal abdominal aortic aneurysm treated by unipolar exclusion and axillobifemoral bypass is reported. The exclusion was performed by inserting inflatable balloons through a femoral access and obstructing the iliac arteries. This technique may be useful in poor-risk patients with a symptom-free aneurysm.

[Cerebral protection by retrograde perfusion in the treatment of acute aortic dissection]

Four consecutive patients underwent resection and graft replacement of ascending aorta or aortic arch for acute dissection. Retrograde cerebral perfusion (RCP) was used during circulatory arrest. RCP at 15 degrees C was administered through the superior vena cava. Duration of cerebral ischaemia and cardiopulmonary bypass averaged 33 and 156 minutes respectively. Retrograde perfusion flow was regulated from 100 to 800 ml/minute to maintain an internal jugular vein pressure of about 25 cm H2O. All patients survived. Three patients awoke neurologically intact. Minor neurological disturbance was found in 1 patient, he was discharged from hospital at day 11 without any detectable neurological deficit. This technique was attractive because it provided a dry operative field unencumbered by perfusion cannulas or clamps, facilitated construction of a more secure distal anastomosis, and avoided the risk of further injury resulting from the aortic cross clamp. It seems that RCP allows longer circulatory arrest time.

The Y graft: myocardial revascularization with both internal thoracic arteries. Evaluation of eighty cases with coronary angiographic assessment

The use of bilateral in situ internal thoracic arteries is restricted by the risk of sternal devascularization, the length of the pedicle, and the necessity to avoid crossing the midline. The aim of this study is to evaluate Y grafts achieved by anastomosing the proximal end of the free right internal thoracic artery to the side of the attached left internal thoracic artery. Y grafts were performed in 80 patients, aged 41 to 74 years (mean age 58.6 years) between May 1991 and September 1992. Two different techniques were used. Thirty-four patients were included in group 1 and 46 in group 2. Seventy-nine grafts were performed from the left internal thoracic artery to the left anterior descending artery. The right internal thoracic artery was anastomosed to the diagonal artery (5 times), the marginal branch (67 times), the circumflex artery (7 times) and the right coronary artery (2 times). Seventy-five complementary saphenous vein bypasses were performed in 58 patients. Operative mortality was 2.5%. Two patients had perioperative myocardial infarcts (2.5%) on nonbypassed sites. Three patients had sternal wound infections (3.7%). Sixty-two patients (80%) were reexamined by angiography at month 6-25 in group 1 and 37 in group 2. Sixty left internal thoracic artery bypass grafts (97%) were patent versus 39 right internal thoracic artery bypass grafts (63%). In group 1, 23 of 25 left internal thoracic artery bypass grafts were patient (92%) versus 12 right internal thoracic artery grafts (48%). In group 2, all 37 left internal thoracic artery bypass grafts were patent (100%) versus 27 right internal thoracic artery grafts (73%). With this procedure, particular attention must be paid to the length of the right internal thoracic artery, and extensive training is required.

[Iatrogenic arteriovenous fistula between the internal mammary artery and the innominate venous trunk. Contribution of digital arteriography in the positive and anatomic diagnosis]

The authors report the case of an arterio-venous fistula between the internal mammary artery and the trunk of the innominate vein following puncture of the internal jugular. The clinical signs of this unusual complication led the authors to list the differential diagnoses which should be considered and to draw attention to the importance of digitalized angiography in anatomical diagnosis.