Endovascular treatment of descending aortic dissection (type B): short- and medium-term results.

BACKGROUND: Optimal treatment of type B dissections is open to debate. The use of endoprostheses is an option that requires evaluation. AIM: To report our experience with endoprostheses in type B aortic dissections. METHODS: We report our short- and medium-term results with covered prostheses for the treatment of acute (n=7) and chronic (n=28) type B aortic dissections. The criteria used to indicate treatment were the same as those usually used for surgery: acute complications or dilated aneurysm. Cover of the main intimal tear was obtained in all cases with an improvement in symptoms in patients with acute dissections. RESULTS: Early mortality was 14.3% (five patients), linked in three cases to the occurrence of a retrograde dissection of the ascending aorta. No neurological complications were observed. Four patients required an additional endovascular and/or surgical procedure. On early control scans, complete thrombosis of the false lumen at the thoracic level was observed in 40% of cases, partial thrombosis in 42.8% and an absence of thrombosis in 11.4%. After a mean follow-up of 20.8 months, one patient died of a pneumopathy. No secondary aneurysm expansion was noted at the thoracic stage whereas three patients presented with dilation of the abdominal aorta. CONCLUSION: The results of treatment of type B dissections with covered endoprostheses are encouraging. However, the morbimortality associated with treatment and the uncertainty of long-term results do not allow the use of this therapeutic option outside the criteria usually recognized to indicate surgery.

[Pseudo-aneurysms of the ascending aorta in patients previously operated for acute aortic dissection]. / Pseudo-anévrismes de l'aorte ascendante chez les patients déjà opérés d'une dissection aortique aiguë. Diagnostic, traitement.

Pseudo-aneurysms of the ascending aorta are a rare but serious complication of surgery for acute dissection of the aorta. The diagnostic methods and surgical technique have changed in recent years. The authors report their experience over a period of 20 years. From January 1981 to December 2001, 21 patients underwent reoperation for pseudo-aneurysms of the ascending aorta. The average age was 54.2 +/- 3 years. Diagnosis is no longer based on aortography but on transthoracic or oesophageal multiplane echocardiography, thoracic spiral computed tomography or magnetic resonance imaging. Four patients presented with a recent history of severe pulmonary oedema. The risk associated with reopening the sternum is avoided by current operative techniques. The authors have chosen anterograde perfusion of the cervical arteries by direct canulation for cerebral protection. The operative mortality at one month is high (30%). All patients who had pulmonary oedema or cardiogenic shock in the immediate preoperative period died. There were no neurological complications. Twelve patients survived and one has to undergo a further operation for recurrence of the pseudo-aneurysm. The authors conclude that patients operated for dissection of the aorta must be followed up. It is important to resect as much as possible of the pathological aorta during the initial operation to avoid the risk of pseudo-aneurysm formation, at least in the proximal segment of the ascending aorta.

[Primary pericardial sarcoma]. / Sarcome primitif du péricarde.

We present the case of a 50 years old male revealed by a recurrent pericardial effusion. The diagnosis of malignancy was confirmed by direct biopsy. The treatment consisted in surgical excision and chemotherapy. The patient was asymptomatic 17 months after surgery.

Cardiac surgery in patients receiving long term hemodialysis. Short and long term results.

AIM: Cardiac surgery carries a high risk in hemodialysis patients and has been questioned for its results; the purpose of this study is to focus on the short and long term results in our institution. METHODS: We retrospectively analyzed the data from 124 hemodialysis patients who underwent cardiac surgery in our unit between January 1980 and December 1998; 14.5% were diabetic; 46% had isolated coronary artery disease (group 1); 29.8% had valvular disease alone (group 2); 14.5% valve and coronary disease (group 3) and 9.6% miscellaneous disease at highest risk (group 4). We analyzed the relationship between several variables (age, sex, hypertension, diabetes, previous myocardial infarction, type of disease, preoperative ejection fraction) and operative mortality (30 days) and late survival. RESULTS: The overall operative mortality was 16.9%. The only risk factor was the type of cardiac disease: operative mortality was higher in groups 3 and 4 combined than in groups 1 and 2 combined (30% versus 12.7%, p=0.07). Ninety-nine patients were followed until January 2002. Late survival rate was 46.6+/-5% at 6 years for all patients, it was significantly better in groups 1 and 2 combined than in groups 3 and 4 combined. The only risk factor for late mortality was arterial hypertension. Fifty-seven patients are still alive, 46 in groups 1 and 2, 11 in groups 3 and 4. Progression of coronary lesions occurred in 6 patients and valvular lesions in 3 patients. The remainder are doing well. CONCLUSION: Cardiac surgery seems to be justified by the severity of the lesions. Its actual results can perhaps, be improved by earlier detection of cardiac disease and better prevention of myocardial hypertrophy and cardiac calcifications.

[Surgery of infectious endocarditis]. / Chirurgie des endocardites infectieuses.

Thirty to fifty percent of patients with infective endocarditis are operated on during the active phase of the disease; this percentage is higher in case of some valvular localizations (aortic), in case of early prosthetic valve endocarditis, in case of some microorganisms (Staphylococcus aureus, gram-negative, fungus, intracellular microorganism). Operative death (at 30 days) is below 10% in native valve endocarditis, close to 50% in early prosthetic valve endocarditis, and below 20% in late prosthetic valve endocarditis. When active infective disease has been healed by medical treatment alone, half the patients need surgery in the first 2 years of follow-up; the indications for surgery are the functional status, the degree of valvular leaks and other lesions, the degree of ventricular dilatation.

[Alcoholic cardiomyopathy and heart transplantation]. / Cardiomyopathie éthylique et transplantation cardiaque.

The recognition of alcoholic cardiomyopathy in patients with dilated cardiomyopathy is essential as they may regress, at least partially in a relatively short period, with abstention. The clinical history is the key to diagnosis because no other specific feature can identify the cause. Between January 1984 and July 1995, 26 candidates for cardiac transplantation with dilated cardiomyopathy and chronic alcoholism improved after withdrawal of alcohol. None of these patients was placed on the surgical waiting list. Patients with ischaemic cardiomyopathy, valvular disease or previous surgery for valvular hypertensive or congenital heart disease, documented viral myocarditis or connective tissue diseases, were excluded. The diagnostic criterion of chronic alcoholism was a total alcohol consumption of 292 kg and a duration of alcohol abuse of over 10 years. In addition to the clinical features, biological, electrocardiographic, echocardiographic and haemodynamic parameters were analysed. The mean age of the patients was 48 +/- 8 years. There were 25 men and 1 woman. The total mean alcohol consumption was 1,492 kg. The average follow-up period was 63 +/- 41 months. The interval between the onset of symptoms and abstention was 25 months. Haemodynamic improvement was observed in 25 cases. The average interval between alcoholic abstention and recovery was 11.7 months. One patient died suddenly. Improvement of symptoms, decrease of the cardiothoracic ratio and improvement of echocardiographic parameters were statistically significant. The increase in angiographic or isotopic ejection fraction and cardiac index and the decrease in mean pulmonary artery pressures were also statistically significant. These results confirmed the diagnosis of alcoholic cardiomyopathy. Therefore, patients with chronic alcohol abuse and dilated cardiomyopathy must be identified and treated for this problem and not placed on the waiting list for cardiac transplantation unless no improvement is observed after about 3 months of abstention.

Active native valve endocarditis: determinants of operative death and late mortality.

BACKGROUND: In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993. METHODS: There were 201 male and 46 female patients (mean age, 45.4 +/- 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (chi2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival. RESULTS: Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% +/- 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% +/- 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found. CONCLUSIONS: Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

Position-related factors in mitral and tricuspid bioprostheses degenerative changes.

We report clinicopathological findings in 15 patients in whom the same bioprosthesis (BP) had been implanted simultaneously in both mitral and tricuspid positions. The aim of the study was to investigate whether position-related factors played an important role in BP degeneration. There were 14 women and 1 man with a mean age of 34 +/- 11 years. The indications for the initial operation were rheumatic in 14 cases and endocarditis in one patient. The mean interval before reoperation was 7.5 +/- 3.3 years. Predominant cause of reoperation was: structural deterioration of both mitral and tricuspid BPs (6), mitral regurgitation (5), tricuspid BP dysfunction (1), para-aortic leak (1), mitro-aortic thrombi (1). Calcific deposits were the principal cause of early deterioration of mitral BPs and the major cause of late tricuspid BPs dysfunction. This lesion was predominantly related to local factors. Cuspal tears were the principal cause of late (> 9 yrs) mitral BP failure and most probably related to mechanical stress. Extensive fibrosis affected only tricuspid bioprostheses. In 7 patients more extensive degenerative changes occurred in bioprostheses in the mitral rather than the tricuspid position (Group I). However, in the remaining eight the magnitude of the changes was very similar in the two positions (Group II). The interval before reoperation was significantly longer in patients of Group II (9.8 yrs, range 5-13) than patients in Group I (4.9 yrs, range 3-6), (p < 0.01). We concluded that position-related factors exert a major role in bioprosthetic failure. These factors are more deleterious in the mitral position than in the tricuspid position.

Video-assisted coronary bypass surgery: clinical results.

OBJECTIVE: Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy. METHODS: Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n = 21) or occlusion (n = 9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (< 0.3 in two patients). The LAD LIMA anastomosis was performed on the beating heart without cardiopulmonary bypass (CPB) in 26 patients. Femoral-femoral CPB was used in three patients because of unstable angina (n = 1) and intramyocardial LAD (n = 2). Conversion to sternotomy and standard CPB was necessary in one patient for extensive endarterectomy of the LAD. RESULTS: There were no operative complications and no reoperations for haemorrhage. Pulmonary infection was observed in one patient and wound infection in one patient. Patients who underwent the complete procedure on the beating heart without conversion or CPB were ready for discharge on the 5th postoperative day (36 h-13 days). Control coronary angiography was performed in 20 patients. In all cases, the graft was patent. In 17 cases, there was a patent graft with no evidence of anastomotic stenosis. An occlusion of the distal segment of the LAD with a retrograde perfusion of the proximal segment and septal branches by the LIMA was found in one case. This patient was symptom-free and the stress test was negative. An anastomotic stenosis was noted in two patients and was treated by angioplasty (n = 1) or conventional surgery (n = 1). CONCLUSION: In conclusion, the efficiency of this minimally invasive approach should be prospectively compared with similar revascularisation with PTCA or surgical approaches using sternotomy with or without CPB.

[Should aortic atheromatous plaques be excised?]. / Faut-il effectuer l'exérèse des plaques d'athéro-thrombose aortique?

Aortic atheromatous plaque is common condition which has no clinical or therapeutical consequences in the majority of cases. Nevertheless, in some cases, clinical symptoms or potential complications may lead to discussion of the therapeutic indications. The usual diagnostic methods are pre- or peroperative transoesophageal echocardiography. CT scan, magnetic resonance imaging and, rarely, arteriography. These investigations are also valuable in assessing the composition of the plaque and evaluating the risk of thrombosis and therefore of systemic embolism. The surgical indications are discussed in three situations. When the atheroma is large, exuberant and stenotic. This is often the case in the abdominal aorta, much less commonly so in the descending thoracic aorta. Secondly, when the atheroma has been complicated by embolism: this applies to all segments of the aorta. Finally, when there is a potential embolic risk, especially neurological, during open heart surgery; this is usually the case in the ascending aorta. The surgical technique in the first two indications is either excision of the atheromatous plaque or of a segment of the aorta with restoration of continuity by a Dacron patch or tube. In the third indication, two attitudes are possible: either not to manipulate the ascending aorta by changing the site of arterial cannulation, not clamping the aorta, and using pediculated arterial grafts to suppress the aortic implantation of the graft, or, conversely, replacing a fragment of the aorta carrying the atheromatous plaque and reestablishing continuity by a Dacron patch or tube, where a saphenous vein graft may be implanted. In conclusion, excision of atheromatous plaque is always possible but rarely justified. It is essentially a palliative procedure.

Pacemaker endocarditis due to Candida albicans: case report and review.

We describe a case of pacemaker endocarditis due to Candida albicans in a patient who responded favorably to combined surgical and antifungal therapy. Only five cases of candidal pacemaker endocarditis have been reported previously. We review these five cases and discuss the clinical presentation and therapy for this disease in comparison with candidal prosthetic valve endocarditis.

[Long term results of the surgical treatment of obstructive hypertrophic cardiomyopathies]. / Résultats à long terme du traitement chirurgical des cardiomyopathies hypertrophiques obstructives.

Between January 1973 and December 1993, 66 patients underwent surgery in our department for hypertrophic obstructive cardiomyopathy; mean basal outflow gradient was 48.4 +/- 36 mmHg, 20 patients had mitral valve lesions. Thirty six patients underwent myotomy-myomectomy alone, 13 mitral valve replacement alone, and 17 both myotomy-myomectomy and mitral valve replacement. The 30-day mortality rate was 7.5% for all patients; predominant risk factors were gender (female), greater cardiothoracic ratio, preoperative episodes of atrial fibrillation and lack of syncope. Overall survival rate (operative mortality included) was 65.3 +/- 8.6% at 13 years. Predominant risk factors for late mortality were the same than above, plus mitral valve replacement; so mitral valve repair, whenever feasible should be undertaken. Forty nine patients are still followed up: 46 are asymptomatic; Doppler mean basal outflow gradient was reduced to 10 +/- 1.4 mmHg. In conclusion, surgery relieves symptoms and outflow obstruction, and allows mitral valve reconstruction.

[Video-surgery for pericardial effusion. Technique and results]. / Vidéo-chirurgie des épanchements péricardiques. Technique et résultats.

Videosurgery is a relatively non-invasive method of draining the pericardium by the creation of a pleuropericardial window. It provides an excellent view of the thoracic cavity and allows selection of pericardial and pleural, pulmonary or mediastinal biopsy sites. The authors report their preliminary results with this technique. Between May 1994 and May 1995, 22 patients with pericardial effusions were operated by videosurgery at the Pitié Hospital. None of the patients had clinical signs of tamponade. The technique consists in introducing, through 2 or 3 thoracic incisions of 15 mm, trocarts allowing passage of an endoscopic camera and different surgical instruments. Access to the thoracic cavity enabled assessment of the pleura, evacuation of pleural effusions (n = 8) and biopsy of pleural nodules (n = 2). One pulmonary biopsy was performed. Opening the pericardium enabled evacuation of pericardial effusions averaging 622 ml. Pericardial biopsies showed appearances suggesting tuberculosis (n = 2), lupic vasculitis (n = 1) and post-radiation pericarditis (n = 1). In other cases, a histologic diagnosis of non-specific pericarditis was made. A biopsy of a pleural nodule showed undifferentiated carcinoma in one case. A pulmonary biopsy revealed the presence of relatively undifferentiated carcinoma. There were no complications related to the technique. There was one recurrence of pericardial effusion at one month in a patient with carcinoma of the lung who had previously had subxiphoid drainage. There were no cases of secondary pericardial constriction. Therefore, videosurgery is a relatively non-invasive and effective technique of pericardial drainage and biopsy. When there is no emergency, it is probably the method of choice in the treatment and diagnosis of pericardial effusions.

The alpha 3 beta 3 gamma complex of the F1-ATPase from thermophilic Bacillus PS3 containing the alpha D261N substitution fails to dissociate inhibitory MgADP from a catalytic site when ATP binds to noncatalytic sites.

ATP hydrolyses by the wild-type alpha 3 beta 3 gamma and mutant (alpha D261N)3 beta 3 gamma subcomplexes of the F1-ATPase from the thermophilic Bacillus PS3 have been compared. The wild-type complex hydrolyzes 50 microM ATP in three kinetic phases: a burst decelerates to an intermediate phase, which then gradually accelerates to a final rate. In contrast, the mutant complex hydrolyzes 50 microM or 2 mM ATP in two kinetic phases. The mutation abolishes acceleration from the intermediate phase to a faster final rate. Both the wild-type and mutant complexes hydrolyze ATP with a lag after loading a catalytic site with MgADP. The rate of the MgADP-loaded wild-type complex rapidly accelerates and approaches that observed for the wild-type apo-complex. The MgADP-loaded mutant complex hydrolyzes ATP with a more pronounced lag, and the gradually accelerating rate approaches the slow, final rate observed with the mutant apo-complex. Lauryl dimethylamide oxide (LDAO) stimulates hydrolysis of 2 mM ATP catalyzed by wild-type and mutant complexes 4- and 7.5-fold, respectively. The rate of release of [3H]ADP from the Mg[3H]ADP-loaded mutant complex during hydrolysis of 40 microM ATP is slower than observed with the wild-type complex. LDAO increases the rate of release of [3H]ADP from the preloaded wild-type and mutant complexes during hydrolysis of 40 microM ATP. Again, release is slower with the mutant complex. When the wild-type and mutant complexes are irradiated in the presence of 2-N3-[3H]ADP plus Mg2+ or 2-N3-[3H]ATP plus Mg2+ and azide, the same extent of labeling of noncatalytic sites is observed. Whereas ADP and ATP protect noncatalytic sites of the wild-type and mutant complexes about equally from labeling by 2-N3-[3H]ADP or 2-N3-[3H[ATP, respectively, AMP-PNP provides little protection of noncatalytic sites of the mutant complex. The results suggest that the substitution does not prevent binding of ADP or ATP to noncatalytic sites, but rather that it affects cross-talk between liganded noncatalytic sites and catalytic sites which is necessary to promote dissociation of inhibitory MgADP.

[Iatrogenic left coronaro-atrial fistula after mitral valve replacement: apropos of a case]. / Fistule coronaro-atriale gauche iatrogène après remplacement valvulaire mitral. A propos d'une observation.

The authors report a case of an iatrogenic fistula between the left circumflex coronary artery and left atrium. The fistula was a complication of reoperation to replace a mitral valvuloplasty annulus by a mechanical hemi-disc prosthesis (Saint Jude Medical). Diagnosis was made by transoesophageal echocardiography and confirmed by coronary angiography. The patient underwent external ligature under cardio-pulmonary bypass.

Cytomegalovirus infection induces high levels of cyclins, phosphorylated Rb, and p53, leading to cell cycle arrest.

Human cytomegalovirus (HCMV) infection stimulates cellular DNA synthesis and causes chromosomal damage. Because such events likely affect cellular proliferation, we investigated the impact of HCMV infection on key components of the cell cycle. Early after infection, HCMV induced elevated levels of cyclin E, cyclin E-associated kinase activity, and two tumor suppressor proteins, p53 and the retinoblastoma gene product (Rb). The steady-state concentration of Rb continued to rise throughout the infection, with most of the protein remaining in the highly phosphorylated form. At early times, HCMV infection also induced cyclin B accumulation, which was associated with a significant increase in mitosis-promoting factor activity as the infection progresses. In contrast, the levels of cyclin A and cyclin A-associated kinase activity increased only at late times in the infection, and the kinetics were delayed relative to those for cyclins E and B. Analysis of the cellular DNA content in the infected cells by flow cytometry showed a progressive shift of the cells from the G1 to the S and G2/M phases of the cell cycle, leading to an accumulation of aneuploid cells at late times. We propose that these HCMV-mediated perturbations result in cell cycle arrest in G2/M.

[Pulmonary thrombectomy in a patient with antiphospholipid syndrome]. / Thrombectomie pulmonaire chez un patient présentant un syndrome des antiphospholipides.

Chronic pulmonary embolism may occur in the antiphospholipid syndrome. Antiphospholipid antibodies including the lupus anticoagulant and anticardiolipin should therefore be searched for systematically in these patients. Blood clotting (lupus anticoagulant) and immunological (anticardiolipin) investigations are complementary; their positivity may be dissociated. If the thrombus is located in the proximal pulmonary artery, surgical thrombectomy is possible. Operative mortality ranges from 12.6% to 20%. The association of oral anticoagulants with low dose aspirin is indicated for the long term treatment of these patients. The role of steroid therapy is discussed. The authors report the case of a patient with antiphospholipid antibodies who successfully underwent surgical removal of a chronic pulmonary embolism.

Extra-annular procedures in the surgical management of prosthetic valve endocarditis.

Severe acute endocarditis can be associated with major destruction of the annulus. Meticulous surgical debridement of friable necrotic material is always necessary and major damage to the annulus of the valve may impair secure seating of the prosthesis. Extra-annular implantation of a prosthesis may be a life-saving procedure when annular implantation is impossible. Between 1978 and 1989, 36 patients underwent extra-annular complex procedures for annular abscesses. The infection involved the aortic prosthesis and the annulus in 22 patients, and the mitral prosthesis and the annulus in 14 patients. In cases of aortic root abscess, a subcoronary valved graft (11 patients), a supracoronary valved conduit (ten patients) or a left ventricle-abdominal aorta valved conduit (one patient) were implanted. In cases of mitral valve endocarditis with extensive annular abscess, intra-atrial insertion of a mitral prosthesis was performed. In such cases, repair of the aortic root with a valved conduit or intra-atrial implantation of a mitral valvular prosthesis can be life saving and can be expected to give excellent long-term results.