Increased cerebral blood flow velocities assessed by transcranial Doppler examination is associated with complement activation after cardiopulmonary bypass.

The role of complement activation on the cerebral vasculature after cardiopulmonary bypass (CPB) is unclear. The goal of the study was to assess whether heparin-coated CPB reduces complement activation, and influences cerebral blood flow velocities (CBFV). Twenty-four patients undergoing coronary surgery were randomly allocated to non-coated (NC-group) or heparin-coated (HC-group) CPB. Complement activation was assessed by measuring sC5b-9. Transcranial Doppler (TCD) was performed on middle cerebral arteries before and after CPB. Systolic (SV), diastolic (DV) and mean (MV) CBFV were measured. Significant increase of sC5b-9 (p=0.003) was observed in the NC-group and CBFV increased after CPB (SV by 27%, p=0.05; DV by 40%, p=0.06; MV by 33%, p=0.04) whereas no changes were detected in the HC-group. TCD values were higher in the NC-group than in the HC-group (SV, p=0.04; DV, p=0.03; MV, p=0.03) although cardiac index, systemic vascular resistance, haematocrit and pCO(2) were similar. Postoperative SV, DV and MV were significantly correlated with sC5b-9 (r=0.583, p=0.009; r=0.581, p=0.009; r=0.598, p=0.007, respectively). Increased CBFV after CPB are correlated to the level of complement activation and may be controlled by heparin-coated circuits.

[Incidence and evolution of thrombotic images within the internal jugular vein following Swan-Ganz catheter insertion in cardiac surgery]. / Incidence et évolution des images thrombotiques dans la veine jugulaire interne après cathétérisme de Swan-Ganz en chirurgie cardiaque.

OBJECTIVES: Insertion of Swan-Ganz catheter for a few days may be necessary in cardiac surgery. This study was aimed at determining the incidence and the evolution of thrombotic images within the internal jugular vein as well as assessing their association with the presence of a prolonged fever at postoperative day 7 in the lack of any documented infection. MATERIAL AND METHODS: All the patients undergoing cardiac surgery had a two-dimensional ultrasonography of internal jugular veins preoperatively, at discharge (day 7) and at postoperative day 90 if thrombotic images were seen at day 7. RESULTS: Sleeve-like and compact thrombotic images have been observed in site of venipuncture in 52 patients (70.3%). None had any residual thrombotic image 90 days after the operation. No clinical thromboembolic migration has been observed. There was no statistical association between the presence of a thrombotic image at the ultrasonography and the duration of catheterization. Moreover, there was no association between the anticoagulation before, during and after the surgery and the presence of a thrombotic image. We found a non-significant association between fever at day 7 and the presence of a thrombotic image within the internal jugular vein. CONCLUSION: Thrombotic images in the internal jugular vein after catheterization are frequent and disappear at day 90. The limited sample size of this study does not provide strong evidence of the role of jugular thrombi in the prolongation of fever after cardiac surgery.

The CarboMedics 'Top-Hat' aortic valve prosthesis: short-term results.

BACKGROUND AND AIM OF THE STUDY: The CarboMedics 'Top-Hat' aortic valve prosthesis has been specifically designed for supra-annular implantation. The aim of this study was to assess the safety of implantation of this prosthesis by reporting the short-term results of follow up. METHODS: Between May 1993 and May 1998, 128 patients (mean age 62.5 +/- 9.8 years; range: 22-76 years) received a CarboMedics 'Top-Hat' prosthesis at our institution. Among patients, 55% were in NYHA functional classes III or IV, and 54.7% had an isolated aortic valve replacement. Associated procedures were: coronary artery bypass grafting (25.7%), double valve replacement (17.1%), treatment of ascending aortic aneurysm (4.7%) and miscellaneous (5.5%). Follow up was 100% complete; total cumulative follow up was 265 patient-years (pt-yr) (range: 2-60 months). RESULTS: The overall mortality rate was 1.5% (two deaths). The operative mortality rate was 0.8% (one death); this patient died from neurological complications after operation for aortic dissection. The other patient died on postoperative day 40 from a massive cerebral hemorrhage. Four patients presented thromboembolic events; in all cases these were reversible ischemic neurologic deficits. One patient had a nonstructural deterioration (endocarditis) and required reoperation. Freedom from mortality was 98.3% at five years (linearized rate of 0.75%/pt-yr). Freedom from thromboembolism was 63.1% at five years (linearized rate 1.5%/pt-yr). CONCLUSION: Short-term results with the CarboMedics 'Top-Hat' prosthesis were satisfactory, with low rates of morbidity and mortality. As this prosthesis has demonstrated a good reliability to date, we have continued its implantation in our institution, and long-term follow up will be necessary to confirm these good early results.

Estimation of intraoperative aortocoronary bypass saphenous vein graft circumference from its preoperative compliance.

The aim of this study was to determine if the intraoperative circumference of aortocoronary saphenous vein bypass grafts could be predicted from preoperative measurement with B-mode ultrasound sonography in 50 patients. The circumference of the saphenous vein was measured during stepwise increments of a thigh congestive cuff from 0 to 60 mmHg. The circumference of the corresponding segment of the coronary bypass vein graft was measured intraoperatively with callipers. The intraoperative circumference was higher (11.8+/-2.3 mm) than the preoperative circumference (10.2+/-2.4 mm, P=0.006) matched to its corresponding intraoperative mean arterial pressure (57+/-15 mmHg). The prediction of the intraoperative circumference by estimation from the preoperative pressure-circumference relationship fitted by a linear model (r = 0.412, P = 0.004) did not improve on the preoperative circumference matched by arterial pressure alone (r = 0.429, P = 0.003). The intraoperative circumference of the graft vein exceeded its preoperative circumference by 12%. Prediction of the intraoperative graft vein circumference is underestimated by a linear model of its preoperative compliance.

Airway compression in children due to congenital heart disease: value of flexible fiberoptic bronchoscopic assessment.

OBJECTIVE: To evaluate the frequency and severity of airway compression due to congenital heart disease in children and validate the use of the fiberoptic bronchoscope to assess them. DESIGN: A retrospective study. SETTING: A single-institutional study in a university hospital. PARTICIPANTS: Seventy-two children with congenital heart disease. INTERVENTIONS: Airway endoscopy was performed in an awake child in cases of clinical and/or radiologic respiratory signs or in cases of preoperative assessment of a cardiac abnormality that is known to accompany airway compression. MEASUREMENTS AND MAIN RESULTS: Endoscopy was well tolerated; 71% of the children had endoscopic abnormalities and 50% had airway compression. The locations of these compressions are the same as those described in the literature in the cases of vascular rings and left-to-right shunts. The other endoscopic findings were laryngeal and bronchial abnormalities, tracheobronchial malacia, respiratory signs of gastroesophageal reflux, and positive bacteriologic sputum samples. CONCLUSION: Endoscopy in an awake patient is the only way to evaluate the functional component of a compression due to malacia; the resulting collapse of the airway can cause trapping of air and secretions. Furthermore, fiberoptic bronchoscopy offers a complete examination of the airways and can help detect airway abnormalities that are potential causes of complications. Fiberoptic bronchoscopy is a suitable and well-tolerated examination that is easy to perform at the bedside of the child. This technique optimizes the preoperative assessment of children with congenital heart disease.

Doppler-echocardiographic assessment of the carbomedics supra-annular 'Top-Hat' prosthetic heart valve in the aortic position.

Twenty-one CarboMedics 'Top-Hat' bileaflet prostheses were implanted in the aortic position between May 1993 and May 1994 at our institution. Valve performance was assessed by repeat echocardiography. We found it very easy to implant this prosthesis even in the small aortic annulus and it allowed us to implant a valve that is at least one size larger than implantation in the intra-annular position allows. The only contraindication to the implantation of this prosthesis is when the coronary ostia are displaced downwards, which would apply to any supra-annular prosthesis. The Doppler echocardiographic assessment showed acceptable transvalvular gradients and velocity indexes. The Top-Hat prosthesis is now our valve of choice in the small aortic annulus.

Diagnostic Evaluation of Postmenopausal Bleeding by Fibrohysteroscopy

The most appropriate fibrohysteroscope is the smallest with which one can perform a biopsy. We use a 3.5- or 4.9-mm flexible hysteroscope during office or hospital ambulatory procedures without anesthesia or cervical dilatation. Our failure rate is below 3%. In a postmenopausal patient with uterine bleeding we do not perform hysteroscopy if the vaginal sonography (VS) detects an endometrial thickness less than 4 mm. At this cut-off limit the calculated risk for not detecting endometrial abnormality is 5.5%. In any other cases we prefer fibrohysteroscopy because its diagnostic accuracy is higher than that of VS, VS can miss focal lesion of hyperplasia or adenocarcinoma incipiens, and abnormal endometrial findings detected by VS and sonohysterography require a directed biopsy during hysteroscopy. A study compared the experience in France with 286 women, in Belgium with 25 women, and in Japan with 44 women. Apart from myoma, the most frequent findings were atrophic normal endometrium (49%), polyps (26.15%), hyperplasia (4.65%), and adenocarcinoma (1.7%). For the follow-up of these patients a decision tree is suggested with the use of VS or fibrohysteroscopy.

[Coronary artery bypass with extracorporeal circulation in a patient with hemophilia B]. / Pontages coronariens avec circulation extracorporelle chez un patient atteint d'une hémophilie B.

A 64-year-old patient with factor IX deficiency (Christmas disease) underwent quadruple coronary bypass grafting for angina pectoris. Excessive bleeding was prevented by infusion of factor IX concentrates from one day before surgery until the 19th postoperative day. The surgical procedure and the cardiopulmonary bypass were carried out in the same manner as in patients without any haemorrhagic disorder. No haemorrhagic complication occurred, neither during nor after the operation.

Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain.

BACKGROUND: Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the brain, especially when the internal jugular vein is valvulated (88% of the cases). This anatomic study was carried out to determine how a liquid injected in the superior vena cava reaches the brain. METHODS: Three groups of adult cadavers (5, 5, and 3 cases, respectively) were injected with latex, colored blue, through a cannula in the superior vena cava. In group I, 600 mL of latex was injected. Group II was identical except that a catheter had been inserted, before the injection, into the internal jugular vein to collapse the internal jugular vein valve, when existing. In group III, the azygos vein was ligated. RESULTS: The internal jugular vein was not valvulated in 2 cases in group I. In those 2 cases, latex was found up to the jugular foramen. In the other cases in group I, and in all cases in group II, where the internal jugular vein was valvulated, the following veins were injected: internal jugular vein up to the valve (almost no latex beyond), azygos vein, inferior vena cava, renal veins, rachidian and perimedullar venous plexuses, and venous sinuses of the brain. In group III, no opacification was observed beyond ligated azygos vein or valvulated internal jugular vein. CONCLUSIONS: Despite the fact that this study was carried out on cadavers, one can assume that, during retrograde cerebral perfusion, the azygos vein system is a major way to the central nervous system when the internal jugular vein is valvulated.

[Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age]. / Chirurgie cardiaque chez les patients âgés; résultats immédiats et à moyen terme chez 100 patients âgés de 75 ans et plus.

With improved operative technique and postoperative care, progressively older patients are being referred for cardiac surgery. One hundred out of 633 patients operated between September 1990 and December 1992, were over 75 years of age (Group I). These patients were compared with the last 100 patients under 75 years of age (Group II). Both groups were operated by the same surgical team with the same anaesthetic, cardiopulmonary bypass and myocardial protection techniques. The average age of the groups was 79.5 +/- 3.1 and 62.1 +/- 9.2 years, respectively. The procedures performed were: myocardial revascularisation (Group I, 28 cases; Group II, 59 cases), aortic valve surgery alone or associated with coronary bypass (56 and 22 cases respectively), and mitral valve surgery alone or associated with another procedure (11 and 12 cases). There were no significant differences between the two groups with respect to true low output state, the duration of mechanical ventilation and of intensive care and hospital stay. On the other hand, there were significant differences in: the number of blood transfusions (44 cases versus 20, p < 0.001), the occurrence of atrial fibrillation (52 cases versus 29, p < 0.001) and neuropsychiatric disturbances (27 cases versus 5, p < 0.0001). There were no cases of mediastinitis in either group. The hospital mortality was 6% in Group I and 5% in Group II (NS). The medium-term mortality after an interval of 5 to 32 months in the over 75 age group was 7 cases, including 4 cases of cerebrovascular accident. An enquiry was performed in the 87 survivors of Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retrograde cerebral perfusion for replacement of the aortic arch. Apropos of a case]. / Perfusion cérébrale rétrograde pour remplacement de la crosse aortique. A propos d'un cas.

The authors report a case of cerebral protection with retrograde cerebral perfusion during aortic arch surgery. The duration of retrograde cerebral perfusion and the favorable neurological outcome seem to confirm the promising results of this technique developed in Japan.

Biochemical and immunohistochemical multiparametric analysis of steroid receptors and growth factor receptors in human normal endometrium in spontaneous cycles and after the induction of ovulation.

This study was carried out with three aims: to assess the variations of receptors for beta-oestradiol and progesterone, and for epidermal growth factor (EGF), alpha-fibroblast growth factor (FGF) and beta-FGF, during a spontaneous cycle in normo-ovulatory patients, 2 days before, and 2 and 7 days after the day of ovulation; to compare the control group of patients with those given ovulation induction using a multiparametric approach; and to study the role of luteal supplementation with progesterone in two groups of patients treated by a luteinizing hormone-releasing hormone agonist plus human menopausal gonadotrophin. The results were assessed by biochemical analyses and by immunohistochemistry. In spontaneous cycles, a decrease in steroid receptors occurred during the luteal phase. There was an increase in EGF and EGF receptors which was induced by oestradiol secretion, and an increase during the luteal phase of alpha-FGF and beta-FGF, which are considered to be angiogenic factors. Comparisons between spontaneous and induced cycles showed a few variations in the endometrium but no differences were related to the type of ovulation induction.

[Long-term retrograde cerebral perfusion in surgery of the aortic arch. Apropos of 2 cases]. / Perfusion cérébrale rétrograde de longue durée dans la chirurgie de la crosse aortique. A propos de deux cas.

The authors present two cases of aortic arch replacement for aortic dissection: one in a male patient 58 years old and the other in a female patient 78 years old. Cerebral protection during repair of the aortic arch was performed with retrograde cerebral perfusion (RCP). Durations of RCP were 75 and 120 minutes respectively. Good neurological recovery in both patients appeared to confirm the efficacy of RCP with respect to cerebral protection during surgery of the aortic arch.

[Early diagnosis of traumatic extra-pericardial luxation of the heart. Value of tomodensitometry. Apropos of a case]. / Diagnostic précoce de la luxation extrapéricardique du coeur d'origine traumatique. Intérêt de la tomodensitométrie. A propos d'un cas.

Heart luxation is a rare complication of chest trauma. The rupture of pericardium must be diagnosed as soon as possible, particularly before prolonged orthopaedic surgery for multitrauma, as a cardiac arrest may occur during anaesthesia. This report underlines the difficulties of diagnosis in a 40-year-old patient with head trauma, chest trauma and multiple fractures. The diagnosis was suspected on unstable blood pressure and left lung atelectasis. The computed tomography showed herniation of the left ventricle. Emergency thoracotomy showed the left rupture of pericardium with complete left heart dislocation. Orthopaedic operation was carried out three days later. Computed tomography in multitrauma patients, seems to be decisive for early diagnosis of heart luxation. Emergency thoracotomy is essential.

[Macroscopic vascularization of the adult sternum. Implications of removal of the internal thoracic arteries]. / Vascularisation macroscopique du sternum adulte. Implications du prélèvement des artères thoraciques internes.

The most of the arterial vascularisation of the adult sternum is on the dependence of the internal thoracic arteries. The best results of the aorto-coronary by-pass starting from this arteries are however subjected to more infectious complications. The study of this arterial supply, in "surgical" conditions, after sternotomy and ablation of one or two internal thoracic arteries show this devascularization. The residual arterial supply is only constituted by thin branches coming from intercostal arteries.

[Iloprost (Ilomedine) and extracorporeal circulation with conventional heparinization in a patient with heparin-induced thrombocytopenia]. / Iloprost (Ilomédine) et circulation extracorporelle avec héparinisation conventionnelle chez un patient ayant une thrombopénie à l'héparine.

A 73-year-old female patient was admitted for myocardial infarction. Conventional treatment with heparin was started, intraaortic balloon assistance was required for several days, together with heparin. The platelet counts decreased progressively, from 288 G.l-1 on admission to 41 G.l-1 on the 16th day, despite the use of low molecular weight heparin. The in vitro heparin platelet aggregation test remained positive. This aggregation ended on adding iloprost, an analogue of prostacyclin, to the platelet culture bath. A coronary aortic bypass graft was required. An infusion of iloprost was started just after induction of anaesthesia. The initial dose of 0.5 ng.kg-1 x min-1 was gradually increased to 20 ng.kg-1 x min-1. Heparin (400 IU.kg-1) was thereafter added. To maintain a mean blood pressure of a least 50 mmHg, an infusion of up to 10 micrograms.kg-1 x min-1 of phenylephrine was given. As it was insufficient, an infusion of up to 1 microgram.kg-1 x min-1 noradrenaline was required. The iloprost infusion was gradually stopped 15 min before the end of CPB, together with that of noradrenaline. Platelet aggregation tests were positive after protamine had been given, whereas they had been negative during the infusion of iloprost. There was no abnormal postoperative bleeding. An infusion of 2 ng.kg-1 x min-1 was started at the sixth postoperative hour for 48 h, until the coumarin-like agent had started taking its effects. It is concluded that iloprost might be useful for carrying out cardiac surgery in patients with heparin-induced thrombocytopaenia.

[Anaphylactic shock during the use of high doses of aprotinin in cardiac surgery]. / Choc anaphylactique lors de l'utilisation de l'aprotinine à fortes doses en chirurgie cardiaque.

A 77-year-old man was admitted for mitral valve replacement, 46 days after a failed conservative mitral surgery where he received high-dose aprotinin. Twenty minutes after induction of anaesthesia, 250 UPh E of aprotinin were infused intravenously; before the end of this infusion, bronchospasm, systemic hypotension and generalized rash were noted. Immediate treatment included intravenous adrenaline and methylprednisolone; cardiovascular stability was restored after 10 minutes. Immediate histamine liberation was confirmed by the analysis of the time course of the clinical events, a previous contact and positive skin tests. Aprotinin has the antigenic molecular structure of natural proteins. Since 1987, it is used in cardiac surgery to reduce postoperative blood loss: to prevent serious allergic reactions to aprotinin, it is necessary, in patients known to have had previous aprotinin therapy, to perform skin testing with diluted aprotinin before infusion.