[A quality program in haemovigilance: evaluation of the blood transfusion chain]. / Démarche qualité en hémovigilance: analyse du processus transfusionnel.

Blood transfusion, like any effective therapy, involves an element of risk. In order to reduce such risks to a maximum, a legislative and statutory framework has been set up. A reliable evaluation of this system is necessary together with an efficient evaluation method whose aim is to guarantee quality service. Favouring the development of the evaluation of professional practices is one of the priorities of the National Agency of Accreditation and Evaluation in Health (ANAES) created in April 1996. Following the recommendations from ANAES, the University Hospital of Brest decided to set up an evaluation of blood transfusion chain from the prescription of blood products to the transfusion act and follow-up of receivers in two health care services. The method used for this evaluation was a clinical audit. It is a method of evaluation, which allows with the help of certain criteria, care practices to be compared to accepted references, in order to measure the quality of these practices and the results of hospital care, so that improvements may be added. We present here the method and results of this evaluation, as well as the improvements we have put in place.

[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]. / Evaluation de la mortalité et de la qualité de vie postopératoire des sujets de plus de 75 ans après remplacement valvulaire pour rétrécissement aortique. A propos de 110 cas.

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?]. / Echec des pontages coronaires avec l'artère thoracique interne. Quelles en sont les causes?

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?]. / Echec des pontages coronaires avec l'artère thoracique interne: l'utilisation extensive de l'artère thoracique interne a-t-elle des conséquences sur la perméabilité des pontages coronaires?

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.

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.

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.

[Left ventricular distribution of retrograde cardioplegia. Should the interventricular posterior vein be occluded in the coronary sinus?]. / Distribution ventriculaire gauche de la cardioplégie rétrograde. Faut-il obturer la veine interventriculaire postérieure dans le sinus coronaire?

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.

[Mechanical system of left ventricle cannulation: control of tightness by experimental left ventricular assistance]. / Système mécanique de canulation ventriculaire apicale: contrôle de l'étanchéité par assistance ventriculaire gauche expérimentale.

We have designed a mechanical device for left ventricular apex cannulation (SCAV). It will be used to implant a ventricular connection for a skeletal muscle ventricle placed in apicoaortic configuration without cardio-pulmonary bypass. The aim of this study was to assess the tightness of the ventricular connection at 48 hours. We used a left ventricular assist device (Biomedicus centrifugal pump) placed between the apex of the left ventricle and the descending thoracic aorta on 10 female sheep. The ventricular connection between the apex of the left ventricle and the Biomedicus was carried out with the SCAV and without cardio-pulmonary bypass. The intra-operative mortality was 10% (1 sheep) due to ventricular fibrillation. Three sheep died early in the run of the ventricular assistance due to technical assistance problems not related to the SCAV. The full ventricular assistance could be managed in 6 sheep through 32 h 30 (range from 15 to 46 h). No death occurred in these 9 sheep due to cardiac hemorrage or tamponade. The average apical bleeding in the pericardial drain was 157 ml (range from 20 to 270 ml). The tightness of the ventricular connection was proved by this study. The SCAV may be suitable for apical implantation of a skeletal muscle ventricle in sheep.

[Angioplasty and coronary restoration using the internal mammary artery]. / Angioplastie et remodelage coronaire avec l'artère mammaire interne.

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%.

Left ventricular papillary fibroelastoma: two-dimensional echocardiographic detection and surgical resection.

We report a patient with a papillary fibroelastoma arising from the left ventricular posterior wall. The tumor was detected incidentally during echocardiography undertaken to evaluate aortic stenosis. Possible complication from tumor embolization was avoided by surgical resection during aortic valve replacement.

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]. / Prise en charge hospitalière et conduite chirurgicale dans les plaies du coeur par arme blanche.

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]. / Perméabilité à 1 an des pontages de l'artère marginale gauche; comparaison de trois 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]. / Complications vasculaires de la chirurgie discale lombaire. A propos de deux cas et d'une revue de littérature de 122 cas.

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.

[Complex coronary reconstructions using the internal mammary artery. Technique of surgical angioplasty, preliminary results]. / Reconstructions coronaires complexes avec l'artère mammaire interne. Technique de l'angioplastie chirurgicale, résultats préliminaires.

A technique of coronary surgical angioplasty is described. The long arteriotomy of the coronary artery over the stenosis is closed with the Internal Thoracic Artery (ITA) giving an enlargement patch effect. The majority of the atheromatous plaque is excluded from the lumen of the anastomosis and placed outside the suture line. The origin of the collateral arteries is preserved in the vascular lumen. The remodeled coronary artery is composed of a small gutter of native coronary artery and the whole surface of the ITA wall. In some cases, it is useful to associate a limited endarterectomy with the angioplasty. 66 surgical angioplasties have been performed in extensive coronary disease. Operative mortality was 5.4% with a myocardial infarction rate of 5.4%.

[Distribution of cardioplegia by retrograde approach. Cannula of retrograde cardioplegia with manually inflating balloon versus self-inflating balloon]. / Distribution de la cardioplégie par voie rétrograde. Canule de cardioplégie rétrograde à ballonnet gonflable manuellement versus ballonnet auto-gonflable.

Retrograde cardioplegia is still debated due to heterogeneous left ventricular flow distribution. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two patterns of cannula. Fifty four patients were prospectively randomized to receive cold crystalloid retrograde coronary sinus cardioplegia with lither a manual inflating balloon cannula (group I, 24 patients) or a self-inflating balloon cannula (group II, 30 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 12 degrees C. In group II, 70.8% of patients had an identical cooling in the anterior and posterior wall of the left ventricle, versus 40.9% in group I (p < 0.05). The mean temperature difference between anterior and posterior wall was 2.9 degrees C (standard deviation: 2.9 degrees C) in group II versus 5.7 degrees C (standard deviation: 4.3 degrees C) for group I (< 0.05). The retroplegia cannula with the self-inflating balloon allows a better distribution of the cardioplegia flow than the manually inflating balloon. We think that this is due to the shape of the self-inflating balloon which more closely fits the morphology of the coronary sinus.

[Ventricular decompression and neuropsychiatric disorders in coronary surgery]. / Décompression ventriculaire et troubles neuro-psychiques dans la chirurgie coronaire.

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.