[Creation of software to help cardiac surgeons: CordaBase].

BACKGROUND: The writing of surgical and hospitalization reports is time-consuming and does not necessarily enable the increment of a statistical database, tool that is indispensable nowadays to evaluate unit activity or to carry out scientific studies. In order to prevent this double data capture, a computer tool, named CordaBase, has been developed by surgeons and set up in a cardiac surgery unit. MATERIALS AND METHODS: CordaBase is an interactive software that stores medical data. Thanks to its intuitive interface, CordaBase stores data which is classified chronologically in the following categories: past medical history, preoperative assessment, operating gesture, stay in intensive care unit, stay in wards and evolution/monitoring after discharge. This date, stored in an Access base, are then used in the creation of personalized surgical and hospitalization reports. All the data is permanently available and can be used for the carrying out of scientific works or for the evaluation of the unit activity. RESULTS: From March 2009 to December 2010, 2617 consecutive patients operated on in a Cardiac Surgery Unit were recorded prospectively in the software. All of this stored data assisted the surgeon in his or her administrative tasks, thanks to personalized surgical and hospitalization reports, immediately at the secretariat's disposal. The database, which is requisitely filled by administrative work, enables the carrying out of any statistical study on all unit activity. CONCLUSION: With a hindsight of almost 2 years, CordaBase has proven its usefulness in an active cardiac surgery unit, both on an administrative and scientific level. The computerized reports have lightened the medical secretariat's workload and statistical studies have now become possible without having to take the paper medical files out again. In the years to come, the accumulation of medical data prospectively or retrospectively stored will surely confirm the potential of the use of such a software.

Superior prevention of acute rejection by tacrolimus vs. cyclosporine in heart transplant recipients--a large European trial.

We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.

[A rare cause of myocardial infarction: papillary fibroelastoma of the aortic valve]. / Cause rare d'infarctus du myocarde: le fibro-élastome papillaire de la valve aortique.

Papillary fibroelastoma is a rare, benign endocardial tumour usually located on the cardiac valves. Before echocardiography, these tumours were chance findings either at surgery or at autopsy. With the advent of echocardiography, the diagnosis has become commoner and they are often the cause of systemic embolism justifying surgical ablation. In this case, an aortic valve papillary fibroelastoma presented with myocardial infarction in a 78 year old woman with normal coronary angiography. The diagnosis was strongly suspected at echocardiography and confirmed by histological analysis of the surgically excised tumour.

Resection of bronchopulmonary cancers invading the left atrium--benefit of cardiopulmonary bypass.

AIMS: Cardiopulmonary bypass (CPB) for extended lung resections involving great vessels and other mediastinal organs remains controversial, especially due to CPB-related haemorrhagic and immunological issues. Here, we will retrospectively analyse the results obtained with such procedure. MATERIAL AND METHODS: Between January 1994 and February 2001, four patients underwent surgery under CPB for lung carcinoma in our department. Three patients were male and one female; mean age was 58.8 +/- 6.3 years. The patients suffered from malignant pulmonary lesions involving the left atrium (T4 or stage IIIb) - two epidermoid carcinoma, one adenocarcinoma and one large-cell carcinoma. Procedures were performed under complete CPB with aortic cross-clamping in all but one patient who underwent hypothermic ventricular fibrillation. Mean CPB duration was 86.7 +/- 26.5 min. RESULTS: There were no hospital mortalities (D30). Mean duration for assisted ventilated support was 9.5 +/- 2.5 hours, 2.5 +/- 1 days for ICU stay and 14.3 +/- 1 days for hospital stay. Operation-related complications were rare. Two patients presented with transient postoperative atrial fibrillation. Only one patient had to undergo reoperation for compressive haemopericardium drainage at D23. The mean quantity of transfused packed red blood cell packs was 2.7 +/- 1.7. Two patients survived over three years after surgery and one patient is still alive at 72 months without any recurrent symptom. CONCLUSION: In some cases of T4 lung cancer considered inoperable, CPB permits extended lung resections offering significant hope for survival at an acceptable operative risk.

Early and 1 year angiographic evaluation of graft patency in off-pump coronary bypass surgery via sternotomy.

The goal of this study was to evaluate the early and 1 year postoperative angiographic results in patients who underwent coronary revascularisation for multivessel disease on beating heart via sternotomy. One hundred eleven consecutive patients receiving 272 grafts, operated by the same surgeon were studied (2.5 grafts/patient). The quality of the graft and the anastomoses was systematically evaluated by coronary angiography between 1 and 15 days after surgery. Eighty-seven patients (209 grafts) of the initial cohort (78.3%) were repeatedly controlled by angiography between 5 and 24 months. Angiographic findings were studied and classified according to Fitzgibbon classification. Overall early graft patency was 96.4%. Arterial graft patency was 96.4% and vein graft patency was 96.3% (P=1). Of the grafts (88.7%) were Grade A, 21 grafts (7.7%) Grade B and 10 grafts (3.6%) were occluded (Grade O). The second angiographic control revealed a patency rate of 94.8%, arterial graft patency was 95.4% and vein graft patency was 93.8% (P=0.9): 91.5% of patent grafts were graded (A), 3.3% graded (B) and 5.2% graded (O). A comparison between early and late angiograms revealed: two-stenosis de novo, three-occlusion de novo and decrease or disappearance of the stenosis in 13/21 graft, 11 arterial and two vein grafts (61.9%). In this study, the early and 1 year postoperative patency rate seems to be equivalent to coronary bypass with pump, however, a randomised study is needed to compare both approaches. Most of the stenosis detected at the early coronary angiography could decrease or disappear, especially in arterial grafts.

Retrospective clinical comparison of Celsior solution to modified blood Wallwork solution in lung transplantation for cystic fibrosis.

OBJECTIVE: To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation. METHODS: From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution. RESULTS: Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant). CONCLUSION: Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.

One-stage repair of aortic isthmus atresia, aortic arch hypoplasia and ascending aorta aneurysm via midline sternotomy and normothermic perfusion.

One-stage repair of aortic isthmus atresia, aortic arch hypoplasia and ascending aorta aneurysm was performed via a standard midline sternotomy. Ascending aortoplasty was performed during a 19-min cardiac arrest. With the heart beating and continuous normothermic perfusion of the upper and lower part of the body, the aortic arch was then enlarged using the Amato technique and the harvested ascending aorta wall as autologous patch. A classical Crafoord procedure then restored continuity between the aortic arch and the descending thoracic aorta.

[Surgery in heart failure (without transplantation)]. / Chirurgie dans l'insuffisance cardiaque (hors transplantation).

Cardiac transplant remains the treatment of reference for end-stage cardiac insufficiency. The very great disparity between the number of grafts available and the number of patients eligible to be included on the transplant list drives some of them to contemplate a surgical alternative in order to improve their clinical condition and to delay as much as possible the date of transplant. The objective is to treat surgically one or several of the lesions causing the cardiac insufficiency. It could be valvular surgery, coronary surgery or a combination of both, ventricular remodelling or cardiomyoplasty. It is coronary revascularisation surgery which gives the most spectacular results on condition that it is aimed at the myocardial zones for which viability has been demonstrated by stress echocardiography or a PET scan.

[Mid-term results of stentless bioprosthesis for aortic valve replacement. Experience in a series of 97 patients]. / Résultats à moyen terme des bioprothèses sans armature dans les remplacements valvulaires aortiques. Expérience nantaise sur une série de 97 patients.

Stentless bioprostheses have been described as valve substitutes of interest for aortic valvular replacement. We studied 97 consecutive patients with a mean age of 72.2 years (40-84) who underwent aortic valvular replacement with 80 Toronto SPV and 17 Freestyle prostheses. Operative mortality was 6.2. With a mean follow-up of 19 +/- 10 months (1-46), 87.2% of the surviving 86 patients underwent an echocardiography performed by the same operator. Mean gradient was 10.9 +/- 3.6 mmHg (4.2-22.6) and effective orifice area was 1.8 +/- 0.5 cm2 (0.8-3.0) for the 75 controlled stentless valves. The best haemodynamic data were obtained with the 25 mm diameter prostheses. One asymptomatic partial dehiscence was observed during monitoring. None of the 15 detected aortic leaks was significant. We observed a significant reduction of the ventricular mass in 41 patients who had undergone pre- and postoperative evaluation (p < 0.0014). Overall survival was 86.8 +/- 4.4% at 2 years. Stentless bioprostheses offered satisfactory haemodynamic results in our series. They however require an implantation technique learning curve as well as a thorough knowledge of the aortic root anatomy and physiology.

Isolated mitral valve replacement with St. Jude medical prosthesis: long-term results: a follow-up of 19 years.

BACKGROUND: In this retrospective study, approximately 440 patients received mitral valve replacements with the St Jude Medical prosthesis. The last patient was operated on 10 years before the beginning of the follow-up. The extended follow-up was 19 years. METHODS AND RESULTS: Four hundred forty patients (sex ratio, 1.32 [men to women]; age, 60+/-11.4 years; age range, 7 to 75 years) were operated on from 1979 to 1987. All patients underwent isolated mitral valve replacement. Tricuspid plasty was the only associated procedure. The follow-up at 19 years was 98% complete. The overall actuarial survival rate was 63+/-3.3% at 19 years, and the actuarial survival rate (only valve related) was 83+/-2.7%. The operative mortality rate (0 to 30 days) was 4.09%. We found that 89.4% of the patients alive at 19 years were in NYHA class I/II. Multivariate analysis showed that age and sex were significantly correlated with valve-related mortality and that age, sex, NYHA class, and atrial fibrillation were significantly correlated with overall mortality. The linearized rates (percent patient-years) of thromboembolism, thrombosis, and hemorrhage were 0.69, 0.2, and 1, respectively. At 19 years, freedom from endocarditis and reoperation was 98.6+/-1% and 90+/-3%, respectively. CONCLUSIONS: In this study, the very-long-term results confirm the excellent durability of the St Jude Medical prosthesis in the mitral position and show the difficulty of adjusting the anticoagulation protocol, even after long-term treatment.

[Cure of superacute eosinophilic myocarditis treated by temporary circulatory assistance]. / Guérison d'une myocardite suraiguë à éosinophiles traitée par assistance circulatoire temporaire.

The authors report the case of a 31 year old woman, admitted as an emergency for acute myopericarditis, in cardiogenic shock. Echocardiography showed severe left ventricular dysfunction associated with concentric biventricular hypertrophy with increased echogenicity of the myocardial walls. Poor response to treatment with intravenous inotropic drugs led to referral for biventricular circulatory assistance with a Biomedicus pump, which was withdrawn on the 9th day after recovery of normal left ventricular function. Myocardial biopsies showed massive interstitial inflammation with a predominance of eosinophilic cells suggesting a hypersensitivity reaction. Steroid therapy was prescribed when the results of biopsy were known and stopped after 6 months. This case emphasises the value of echocardiography and myocardial biopsy in diagnosis and treatment of acute myocarditis with cardiogenic shock.

[Surgical treatment of pulmonary metastases of colorectal cancers. 8-year survival and main prognostic factors]. / Traitement chirurgical des métastases pulmonaires des cancers colorectaux. Survie à 8 ans et principaux facteurs pronostiques.

OBJECTIVE: In order to achieve a better definition of the indications for surgical excision of pulmonary metastases in colorectal cancer (CCR), a retrospective study of the eight year survival of patients who had been operated on was carried out with reference to the principal prognostic factors. METHODS AND RESULTS: Between May 1986 and December 1997, 38 patients had an excision for pulmonary metastases for CCR. The mean delay between diagnosis of the metastases and surgical treatment of the CCR was 39 +/- 24 months (0-98). Thirty two patients (84%) had a single pulmonary metastasis. The mean diameter of the metastasis was 38 +/- 22 mm. Twenty metastases had a diameter < 30 mm. Five patients had a locoregional recurrence of their CCR before pulmonary surgery. Fourteen patients had an abnormally elevated level of carcinoembrionic antigen (ACE-CEA) before the pulmonary excision. Five pneumonectomies, 23 lobectomies, 1 bilobectomy and 11 atypical resections were carried out. A lymph node clearance was performed in 25 cases. Six patients (16%) had an associated excision of an hepatic metastasis. The in-hospital mortality was 2.6%. Chemotherapy was associated with a pulmonary excision in 17 patients (46%). The mean survival was 2.7 years (0.13-8.7 years). The survival at one year was 89 +/- 5.2% and at five years 35.2 +/- 10.1% and at eight years 18.8% +/- 10.3%. Age, sex, histological stage of the primary tumor, the size and the delay in appearance in the pulmonary metastases, the number of metastases, the preoperative CEA, the operative technique and the perioperative chemotherapy did not influence the levels of survival at five years. At the same time associated excision of an hepatic metastasis did not worsen the prognosis at five years. CONCLUSION: Complete excision of pulmonary metastases in a colorectal cancer allows for significantly longer survival. This study associated with a literature review may help in advancing towards better selection of surgical candidates.

[Mucoviscidosis: lung transplantation is always in order]. / Mucoviscidose: la transplantation pulmonaire toujours d'actualité.

THE ONLY SOLUTION: Despite significant progress in the management of patients with multiple sclerosis, lung transplantation remains the only chance for survival in those with severe respiratory failure. WAITING LIST INCLUSION CRITERIA: Lung function tests, the patientís general states and psychological and familial factors all contribute to determining inscription on lung transplantation waiting lists. TECHNICAL ASPECTS: Heart-lung, monoblock two-lung and sequential two-lung transplantations are detailed according to the respective advantages and disadvantages. RESULTS: Hospital mortality is about 5% and 5-year survival about 50%. However, only 10% of the patients on waiting lists due to the lack of organs survive for 2 years. PERSPECTIVES: The number of grafts must be increased by developing lobular grafts from live donors using the bipartition technique. Nevertheless, xenografts remain the most promising perspective for increasing the number of patients who can benefit from this therapy.

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer.

OBJECTIVE: Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS: Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS: The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS: Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.